Individual
MR. WILEY D PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
134 W CHUBBUCK RD, CHUBBUCK, ID 83202-2338
(208) 417-0102
(208) 242-3219
Mailing address
5014 MARY LN, POCATELLO, ID 83202-1679
(208) 241-5819
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-1714
ID
Other
Enumeration date
03/04/2019
Last updated
05/17/2024
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