Provider Demographics
NPI:1598705667
Name:PETERSON, GREGORY WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WAYNE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E 2ND ST
Mailing Address - Street 2:STE 327
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-6354
Mailing Address - Country:US
Mailing Address - Phone:507-452-6640
Mailing Address - Fax:
Practice Address - Street 1:902 E 2ND ST
Practice Address - Street 2:STE 327
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-6354
Practice Address - Country:US
Practice Address - Phone:507-452-6640
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor