Provider Demographics
NPI:1538138821
Name:PETERSON, LON B (MD)
Entity Type:Individual
Prefix:DR
First Name:LON
Middle Name:B
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 1:1285 NININGER RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-1086
Mailing Address - Country:US
Mailing Address - Phone:651-480-4200
Mailing Address - Fax:651-480-4306
Practice Address - Street 1:1285 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1086
Practice Address - Country:US
Practice Address - Phone:651-480-4200
Practice Address - Fax:651-480-4306
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080108727OtherRAILROAD MEDICARE
MN507782600Medicaid
MNFP9703OtherAMERICAS PPO
MNHP16949OtherHEALTH PARTNERS
MN01-00067OtherMEDICA
MN31362000OtherMEDICAID WI
MN4K544PEOtherBLUE CROSS
MN66-02249OtherMEDICA URGENT CARE
MN100055OtherUCARE MINNESOTA
MN31362000OtherGROUP HEALTH EAU CLAIRE
MNNA9141001149OtherPREFERRED ONE