Healthcare Provider Details

I. General information

NPI: 1083902126
Provider Name (Legal Business Name): PAUL H PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 109TH AVE NE STE 100
BLAINE MN
55449-3603
US

IV. Provider business mailing address

1420 109TH AVE NE STE 100
BLAINE MN
55449-3603
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-5880
  • Fax: 763-581-5551
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number912
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: