Provider Demographics
NPI:1598139388
Name:PETERKA, MITCHELL DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DAVID
Last Name:PETERKA
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 1:1000 W 140TH ST UNIT 201
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4833
Mailing Address - Country:US
Mailing Address - Phone:952-808-3000
Mailing Address - Fax:952-808-3001
Practice Address - Street 1:1000 W 140TH ST UNIT 201
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4833
Practice Address - Country:US
Practice Address - Phone:952-808-3000
Practice Address - Fax:952-808-3001
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13022363AS0400X
COPA.0004490363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical