Provider Demographics
NPI:1447122445
Name:PETERS, MARY COLLEEN (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:PETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:101 ELM AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2222
Mailing Address - Country:US
Mailing Address - Phone:540-985-8483
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-985-8483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant