Provider Demographics
NPI:1871164863
Name:PETERSON, PATRICIA JANE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 ALDERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-6559
Mailing Address - Country:US
Mailing Address - Phone:530-736-9730
Mailing Address - Fax:
Practice Address - Street 1:201 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-2506
Practice Address - Country:US
Practice Address - Phone:530-246-3511
Practice Address - Fax:530-246-2672
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist