Healthcare Provider Details

I. General information

NPI: 1902805518
Provider Name (Legal Business Name): PAUL CHARLES PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-7891
  • Fax: 320-255-5882
Mailing address:
  • Phone: 320-255-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number200300395
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number200300395
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number200300395
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number64851
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: