Provider Demographics
NPI:1285636423
Name:PETERSON, KIRSTEN D (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:D
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 WASHINGTON AVE E
Practice Address - Street 2:
Practice Address - City:FINLEY
Practice Address - State:ND
Practice Address - Zip Code:58230-3031
Practice Address - Country:US
Practice Address - Phone:701-524-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37385207R00000X
ND5959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E70334Medicare UPIN