Healthcare Provider Details

I. General information

NPI: 1275462947
Provider Name (Legal Business Name): PETER NIELSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 REANEY AVE
SAINT PAUL MN
55106-4412
US

IV. Provider business mailing address

799 REANEY AVE
SAINT PAUL MN
55106-4412
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberY045211447509
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: