Provider Demographics
NPI:1710524970
Name:PETERSON, SEAN WIBERG (MS LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:WIBERG
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 E 5TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-3809
Mailing Address - Country:US
Mailing Address - Phone:218-590-5397
Mailing Address - Fax:
Practice Address - Street 1:1810 CATLIN AVE
Practice Address - Street 2:ROOM 1246
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-395-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32032255A2300X
WI2201-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer