Provider Demographics
NPI:1770694945
Name:PETERSON, BRIANA MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRIANA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 E MIDDLE TPKE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3730
Mailing Address - Country:US
Mailing Address - Phone:860-646-4334
Mailing Address - Fax:860-646-7020
Practice Address - Street 1:574 E MIDDLE TPKE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-646-4334
Practice Address - Fax:860-646-7020
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001595363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02981Medicare PIN
CTQ38692Medicare UPIN