Provider Demographics
NPI:1538203476
Name:PETERSEN, MICHELLE A (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:BULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4004 PIONEER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7548
Mailing Address - Country:US
Mailing Address - Phone:402-484-4900
Mailing Address - Fax:402-484-6456
Practice Address - Street 1:4004 PIONEER WOODS DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-7548
Practice Address - Country:US
Practice Address - Phone:402-484-4900
Practice Address - Fax:402-484-6456
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001911363A00000X
NE1204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI0923104Medicare PIN
Q58900Medicare UPIN