Provider Demographics
NPI:1730285693
Name:PETER, LINDA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:RAE
Last Name:PETER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51057 155TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-6191
Mailing Address - Country:US
Mailing Address - Phone:507-440-1603
Mailing Address - Fax:
Practice Address - Street 1:2199 HIGHWAY 36 E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-2215
Practice Address - Country:US
Practice Address - Phone:651-779-5986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant