Provider Demographics
NPI:1043305956
Name:PETERSON, EDITH C (ANP)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-374-5353
Mailing Address - Fax:518-347-1413
Practice Address - Street 1:1424 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5101
Practice Address - Country:US
Practice Address - Phone:315-724-6146
Practice Address - Fax:315-797-9671
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY371556163W00000X
NYF-302355363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY346874OtherMVP
NYMP-0693677OtherDEA