Provider Demographics
NPI:1861542086
Name:PETERSON, MICHAEL C (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
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 1:8655 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-9404
Mailing Address - Country:US
Mailing Address - Phone:440-255-7938
Mailing Address - Fax:440-255-9196
Practice Address - Street 1:LHPG MENTOR FAMILY PRACTICE
Practice Address - Street 2:8655 MARKET STREET
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-255-7938
Practice Address - Fax:440-255-9196
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.002538OtherOHIO LICENSE