Provider Demographics
NPI:1104851971
Name:PETERSON, THOMAS ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANDREW
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1300
Mailing Address - Country:US
Mailing Address - Phone:218-834-7727
Mailing Address - Fax:218-834-7727
Practice Address - Street 1:325 11TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1300
Practice Address - Country:US
Practice Address - Phone:218-834-7727
Practice Address - Fax:218-834-7727
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN097792600Medicaid
MN080015187Medicare PIN
MNE52383Medicare UPIN
MN080015186Medicare PIN
MN080116125Medicare PIN
MN089005440Medicare PIN