Provider Demographics
NPI:1548578065
Name:PETERSON, DANIEL LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1706
Practice Address - Country:US
Practice Address - Phone:952-456-7000
Practice Address - Fax:952-456-7001
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10811363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical