Healthcare Provider Details

I. General information

NPI: 1720341225
Provider Name (Legal Business Name): JOSHUA JERALD PELTIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MC11102F
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST MC11102F
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3666
  • Fax: 651-254-5216
Mailing address:
  • Phone: 651-254-3666
  • Fax: 651-254-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number63763-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number59212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: