Provider Demographics
NPI:1093167165
Name:PETERSON, TRACY (PTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HARVARD ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0363
Mailing Address - Country:US
Mailing Address - Phone:612-273-8922
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:MAYO 450/ MMC 106
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:612-273-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2069225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant