Blair Shackleton Peterson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA09776 Issued in TX

Practice address

8440 Walnut Hill LN Ste 610
Dallas, TX 75231-3815

Phone

(214) 345-6000

Fax

(214) 345-6026

NPI assigned

Mar 24, 2015

Sex

Female

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 1

Other names 1

• Blair Leah Shackleton Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

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

{
    "created_epoch": "1427155200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1550620800000",
    "number": "1235523721",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8440 WALNUT HILL LN STE 610",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752313815",
            "telephone_number": "214-345-6000",
            "fax_number": "214-345-6026"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8440 WALNUT HILL LN STE 610",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752313815",
            "telephone_number": "214-345-6000",
            "fax_number": "214-345-6026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "BLAIR",
        "middle_name": "SHACKLETON",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-03-24",
        "last_updated": "2019-02-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA09776",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "354191401",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "BLAIR",
            "last_name": "SHACKLETON",
            "middle_name": "LEAH",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Walter Russell Peters Jr., M.D., M.B.A
• Henry Petersen
• Katharine Petersen, M.D.
• Katherine Petersen, MD
• Robert Todd Petersen, DC, OPAC, ATC, LAT
• Brittany Alese Peterson, FNP-C
• Christina Peterson, RN
• Clifton Peterson
• Eric Peterson, M.D.
• Gail Elizabeth Peterson, MD

• Physician Assistant in Dallas, TX
• Providers in Dallas, TX by specialty
• Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2019; 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.