Provider Demographics
NPI:1518166982
Name:PETERSON, LINDA MARIE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:MARIE
Other - Last Name:GITS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2545 CHICAGO AVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-871-7639
Practice Address - Fax:612-872-0302
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR115880-9367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR115880-9OtherMN RN LICENSE