Provider Demographics
NPI:1629052774
Name:PETERSON, ROBERT A
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-993-6450
Mailing Address - Fax:952-993-0300
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:PARK NICOLLET CLINIC-SLP
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-993-5041
Practice Address - Fax:952-993-1361
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine