Healthcare Provider Details

I. General information

NPI: 1124936018
Provider Name (Legal Business Name): ROBERT PETERSON CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 NORTHLAND DR
PRINCETON MN
55371-2172
US

IV. Provider business mailing address

331 WOOD ST S
MORA MN
55051-1452
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-5000
  • Fax:
Mailing address:
  • Phone: 612-227-7924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number186235
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: