Timothy K. Peterson, PA-C
Individual provider Active NPI Physician Assistant · Roma, TX
NPI 1992887376 · NPPES record last updated Aug 31, 2018
Key facts
- NPI
- 1992887376
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- PA02080 (TX)
- Practice address
- 2891 E Grant St
Roma, TX 78584 - Phone
- (956) 849-2100
- NPI assigned
- Oct 19, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MI, TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040614000535 | MI | Practitioner - Physician Assistant | 1658355201 | Reassigns benefits to 1 organization |
| I20160127000821 | TX | Practitioner - Physician Assistant | 1658355201 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Patient One Care PLLC | Current |
Accepting new patients | |
| Spectrum Health Hospitals | Past | Accepting new patients | |
| Patient One Care, PLLC | Past | Accepting new patients |
Locations
1740 28th St SE
Grand Rapids, MI 49508
Phone (616) 200-8669
2871 44th St SW
Grandville, MI 49418
Phone (616) 410-7420
345 Baldwin St
Jenison, MI 49428
Phone (616) 294-8881
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA02080 | TX | Yes |
Addresses
Primary practice location
2891 E Grant St
Roma, TX 78584
Mailing address
209 N Charco Blanco Rd Apt C
Rio Grande City, TX 78582-3088
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 354895001 | Medicaid | TX |
Other providers in Roma, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 31, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.