Healthcare Provider Details

I. General information

NPI: 1821057662
Provider Name (Legal Business Name): JANE MARIE PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 1ST ST
PAYNESVILLE MN
56362-1445
US

IV. Provider business mailing address

200 W 1ST ST
PAYNESVILLE MN
56362-1445
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-3779
  • Fax: 320-243-7509
Mailing address:
  • Phone: 320-243-3779
  • Fax: 320-243-7509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38050
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: