Individual
MATTHEW R PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
10010 KENNERLY RD, SAINT LOUIS, MO 63128-2106
(314) 525-1911
Mailing address
102 DEL RIO CT, BELLEVILLE, IL 62221-3181
(847) 691-3958
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
085-002763
IL
363A00000X
Physician Assistant
2008025807
MO
363A00000X
Physician Assistant
Primary
85-002763
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1072542
PHYSICIAN ASSISTANT CERTI
—
Enumeration date
08/31/2006
Last updated
11/15/2019
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