Individual
TREVOR PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
777 N RAYMOND ST, BOISE, ID 83704-9251
(208) 514-2500
Mailing address
777 N RAYMOND ST, BOISE, ID 83704-9251
(208) 514-2500
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA213384
OR
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
09/03/2021
Last updated
08/07/2024
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