MEDICARE: JESSICA ANNE FASHANT-PETERSON CNP

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	207Q00000X	Family Medicine Physician	R161940-3	MN

General Provider Information

NPI Number	:	1609109982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANNE FASHANT-PETERSON CNP

Provider Business Mailing Address
First Line	:	6452 CITY WEST PARKWAY
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344
Country	:	US
Telephone Number	:	952-999-0333
Fax Number	:	952-300-2558

Provider Business Practice Location Address
First Line	:	6452 CITY WEST PKWY
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-3245
Country	:	US
Telephone Number	:	952-999-0333
Fax Number	:	952-300-2558

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

Provider Enumeration Date	:	09/17/2009
Last Update Date	:	05/22/2017

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