Individual
SUSAN K. PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
11143 PARKVIEW PLAZA DR, 100, FORT WAYNE, IN 46845-1727
(260) 484-8830
(260) 483-1911
Mailing address
11143 PARKVIEW PLAZA DR, 100, FORT WAYNE, IN 46845-1727
(260) 484-8830
(260) 483-1911
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
10000342A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000528371
ANTHEM PIN
IN
Enumeration date
08/30/2006
Last updated
10/29/2009
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