Healthcare Provider Details

I. General information

NPI: 1003008525
Provider Name (Legal Business Name): JONATHON R PETERSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PLEASANT AVE S
PARK RAPIDS MN
56470-1440
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-732-2800
  • Fax:
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7998
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1585
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: