Healthcare Provider Details

I. General information

NPI: 1487991113
Provider Name (Legal Business Name): COLE WILLIAM PETERSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SNELLING AVE N
FALCON HEIGHTS MN
55113-5730
US

IV. Provider business mailing address

1900 SNELLING AVE N
FALCON HEIGHTS MN
55113-5730
US

V. Phone/Fax

Practice location:
  • Phone: 612-581-3250
  • Fax:
Mailing address:
  • Phone: 612-581-3250
  • Fax: 612-626-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2105
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: