Provider Demographics
NPI:1124192125
Name:PETERS, MYA LYN
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:LYN
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYA
Other - Middle Name:LYN
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6196 BIRCHWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-493-3304
Mailing Address - Fax:
Practice Address - Street 1:225 NORTH SMITH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-726-6900
Practice Address - Fax:651-688-7570
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography