Healthcare Provider Details

I. General information

NPI: 1598698029
Provider Name (Legal Business Name): PAIGE PETERSON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9055 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5841
US

IV. Provider business mailing address

9055 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5841
US

V. Phone/Fax

Practice location:
  • Phone: 763-780-9155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3622
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: