Provider Demographics
NPI:1730274523
Name:PETERSEN, AMY K (DO)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 LAKE DR STE 260
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2504
Mailing Address - Country:US
Mailing Address - Phone:515-630-5022
Mailing Address - Fax:515-630-5026
Practice Address - Street 1:6800 LAKE DR STE 260
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-2504
Practice Address - Country:US
Practice Address - Phone:515-630-5022
Practice Address - Fax:515-630-5026
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics