Provider Demographics
NPI:1578257796
Name:PETERSON, JOSEPHINE ANN
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WAYZATA BLVD E STE 210
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1915
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:952-443-4604
Practice Address - Street 1:1120 WAYZATA BLVD E STE 210
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1915
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:952-443-4604
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program