Provider Demographics
NPI:1689230450
Name:PETERSON, NICHOLAS EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 W LAKE ST UNIT 325
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-6810
Mailing Address - Country:US
Mailing Address - Phone:651-707-4042
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ STE 7236
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0222
Practice Address - Country:US
Practice Address - Phone:651-707-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29803208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation