Provider Demographics
NPI:1447688312
Name:PETERSON, ANNE M
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:M
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3399 E LOUISE DR
Practice Address - Street 2:STE 400
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5047
Practice Address - Country:US
Practice Address - Phone:208-364-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA112363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical