MEDICARE: KATIE MARIE PETERSON AGNP

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	363LG0600X	Gerontology Nurse Practitioner	AG0614152	MN
2	363L00000X	Nurse Practitioner	3298	MN

General Provider Information

NPI Number	:	1508265331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE MARIE PETERSON AGNP

Provider Business Mailing Address
First Line	:	8170 33RD AVE S # MS 21110Q
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-4516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3931 LOUISIANA AVE S
Second Line	:	SUITE E202
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55426-5000
Country	:	US
Telephone Number	:	952-993-9184
Fax Number	:

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

Provider Enumeration Date	:	08/18/2014
Last Update Date	:	03/10/2021

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