Individual
MR. MARK A PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
7540 22ND AVE, KENOSHA, WI 53143
(262) 656-7800
(262) 656-7810
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
575-023
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42924400
—
WI
Enumeration date
08/23/2006
Last updated
04/18/2024
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