Provider Demographics
NPI:1619135860
Name:PETERSON, ELIZABETH JOANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JOANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JOANNE
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:911 NORTHLAND DR,
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371
Mailing Address - Country:US
Mailing Address - Phone:763-389-1313
Mailing Address - Fax:
Practice Address - Street 1:911 NORTHLAND DR.
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1737
Practice Address - Country:US
Practice Address - Phone:763-389-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine