Healthcare Provider Details

I. General information

NPI: 1003882010
Provider Name (Legal Business Name): JONATHAN PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 GRANT BLVD W
WABASHA MN
55981-1042
US

IV. Provider business mailing address

1200 GRANT BLVD W
WABASHA MN
55981-1042
US

V. Phone/Fax

Practice location:
  • Phone: 651-565-5908
  • Fax: 651-565-5910
Mailing address:
  • Phone: 651-565-5908
  • Fax: 651-565-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number33320
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: