MEDICARE: MS. ALEXIS JOAN PETERSON PA-C

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	363AM0700X	Medical Physician Assistant	9098	MN

General Provider Information

NPI Number	:	1306898754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALEXIS JOAN PETERSON PA-C

Provider Business Mailing Address
First Line	:	19685 PILOT KNOB RD
Second Line	:
City	:	FARMINGTON
State	:	MN
Zip	:	55024-7238
Country	:	US
Telephone Number	:	651-463-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	19685 PILOT KNOB RD
Second Line	:
City	:	FARMINGTON
State	:	MN
Zip	:	55024-7238
Country	:	US
Telephone Number	:	651-463-5100
Fax Number	:

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	12/16/2014

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