Healthcare Provider Details

I. General information

NPI: 1104786532
Provider Name (Legal Business Name): MARCUS PETERSON CGC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 LOUISIANA AVE S
ST. LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

8170 33RD AVE S MAIL STOP 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3230
  • Fax: 952-993-1748
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number1748
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: