MEDICARE: MITCHELL PETERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician

General Provider Information

NPI Number	:	1164962213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL PETERSEN

Provider Business Mailing Address
First Line	:	4251 SUNRISE RD
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-2246
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 VANDALIA ST
Second Line	:	175
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1833
Country	:	US
Telephone Number	:	651-313-6733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2017
Last Update Date	:	03/07/2017

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Directions to “ MITCHELL PETERSEN ” Practice Location

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