Provider Demographics
NPI:1003809062
Name:PETERSON, BARBARA LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2315
Mailing Address - Country:US
Mailing Address - Phone:651-699-3115
Mailing Address - Fax:
Practice Address - Street 1:1619 DAYTON AVE
Practice Address - Street 2:STE 205
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6206
Practice Address - Country:US
Practice Address - Phone:651-645-0478
Practice Address - Fax:651-642-2523
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8983363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical