Provider Demographics
NPI:1124029756
Name:PETERSON, KRISTIN LB (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LB
Last Name:PETERSON
Suffix:
Gender:F
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:CHILDREN'S HEALTH CARE
Mailing Address - Street 2:2910 CENTRE POINTE DRIVE 35-121A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:CHILDREN'S PRIMARY CLINIC - STPL
Practice Address - Street 2:347 NORTH SMITH AVENUE
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6789
Practice Address - Fax:651-220-6807
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400042100Medicaid
370002978Medicare ID - Type Unspecified
H16399Medicare UPIN