Healthcare Provider Details

I. General information

NPI: 1003809062
Provider Name (Legal Business Name): BARBARA LYNN PETERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 DAYTON AVE STE 205
SAINT PAUL MN
55104-6206
US

IV. Provider business mailing address

1515 FAIRMOUNT AVE
SAINT PAUL MN
55105-2315
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-0478
  • Fax: 651-642-2523
Mailing address:
  • Phone: 651-699-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8983
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: