Healthcare Provider Details

I. General information

NPI: 1740602960
Provider Name (Legal Business Name): MICHAEL PETERSEN DVM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5754 NICOLLET AVE
MINNEAPOLIS MN
55419-2415
US

IV. Provider business mailing address

5754 NICOLLET AVE
MINNEAPOLIS MN
55419-2415
US

V. Phone/Fax

Practice location:
  • Phone: 612-866-7103
  • Fax: 612-866-0250
Mailing address:
  • Phone: 612-866-7103
  • Fax: 612-866-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number04212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: