Provider Demographics
NPI:1083621445
Name:PETERSON, MARY E (CANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W12070 STATE HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:STOCKHOLM
Mailing Address - State:WI
Mailing Address - Zip Code:54769-6127
Mailing Address - Country:US
Mailing Address - Phone:715-821-8532
Mailing Address - Fax:715-598-6202
Practice Address - Street 1:W12070 STATE HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:STOCKHOLM
Practice Address - State:WI
Practice Address - Zip Code:54769-6127
Practice Address - Country:US
Practice Address - Phone:715-821-8532
Practice Address - Fax:715-598-6202
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0360774363L00000X
WI4576-033363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0404556OtherMEDICA
MN090M9PEOtherBLUE CROSS BLUE SHIELD
MN243994800Medicaid
MN500002042Medicare ID - Type Unspecified
MN243994800Medicaid