Provider Demographics
NPI:1083902126
Name:PETERSON, PAUL H (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 109TH AVE NE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 109TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-3603
Practice Address - Country:US
Practice Address - Phone:763-581-5880
Practice Address - Fax:763-581-5551
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN912213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist