Provider Demographics
NPI:1720388218
Name:PETERSON, TIMOTHY WARREN (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WARREN
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-903-0268
Mailing Address - Fax:859-428-1444
Practice Address - Street 1:405 VIOLET RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8956
Practice Address - Country:US
Practice Address - Phone:859-903-0268
Practice Address - Fax:859-428-1444
Is Sole Proprietor?:No
Enumeration Date:2010-10-30
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1799363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100252800Medicaid
KYK096660Medicare PIN
KYK096661Medicare PIN