Provider Demographics
NPI:1730673757
Name:PETERSON, KAITLIN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:763-520-7870
Mailing Address - Fax:763-520-7580
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:962-456-7000
Practice Address - Fax:952-456-7001
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-08-03
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Provider Licenses
StateLicense IDTaxonomies
MN12759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant