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NPI Code Detail

MEDICARE: DR. SHELLY LEA LARSON-PETERS M.D.

MEDICARE: DR. SHELLY LEA LARSON-PETERS M.D.
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
12084N0400XNeurology Physician50897MN

General Provider Information

NPI Number : 1336333509
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHELLY LEA LARSON-PETERS M.D.
Provider Business Mailing Address
First Line : 3601 MINNESOTA DR STE 200
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55435-5281
Country : US
Telephone Number : 612-879-1000
Fax Number : 612-879-9116
Provider Business Practice Location Address
First Line : 11091 ULYSSES ST
Second Line : SUITE 100
City : BLAINE
State : MN
Zip : 55434-4238
Country : US
Telephone Number : 612-879-1000
Fax Number : 612-879-9116
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2007
Last Update Date : 07/30/2023

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Directions to “ DR. SHELLY LEA LARSON-PETERS M.D.” Practice Location

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