Winston N Petersen, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

262207-1206 Issued in UT

Practice address

800 Falls Ave
Suite 2
Twin Falls, ID 83301-3366

Phone

(208) 734-6091

Fax

(208) 734-4654

NPI assigned

Oct 17, 2005

Last updated

Apr 29, 2016By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 9

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Asthma & Allergy of Idaho

  • Nurse Practitioner
  • Twin Falls, ID
  • NPI 1265635171
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1129507200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1461888000000",
    "number": "1194714717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "811 N 900 W",
            "city": "OREM",
            "state": "UT",
            "postal_code": "840577701",
            "telephone_number": "801-434-7600",
            "fax_number": "801-434-7604"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 FALLS AVE",
            "address_2": "SUITE 2",
            "city": "TWIN FALLS",
            "state": "ID",
            "postal_code": "833013366",
            "telephone_number": "208-734-6091",
            "fax_number": "208-734-4654"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "WINSTON",
        "middle_name": "N",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-10-17",
        "last_updated": "2016-04-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "262207-1206",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807969000",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "PAG40",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "PAG41",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD",
            "identifier": "000010165444",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD OF ID",
            "identifier": "000010165445",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD OF ID",
            "identifier": "000010165446",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807969002",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "PAG39",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807969001",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Haaris Pervaiz, MD
• Amanda Petersen, FNP-BC, RN
• Brendan Petersen, CRNA
• Kenneth Ryan Petersen, DPT, CSCS
• Scott Trevor Petersen, PHARMD
• Kirk C Peterson, MD
• Kylan D Peterson, D.O.
• Nathan Michael Peterson, DDS
• Jay Phan
• Seth Phillips, PT

• Physician Assistant in Twin Falls, ID
• Providers in Twin Falls, ID by specialty
• Physician Assistant in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.