Provider Demographics
NPI:1740602960
Name:PETERSEN, MICHAEL (DVM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5754 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2415
Mailing Address - Country:US
Mailing Address - Phone:612-866-7103
Mailing Address - Fax:612-866-0250
Practice Address - Street 1:5754 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-2415
Practice Address - Country:US
Practice Address - Phone:612-866-7103
Practice Address - Fax:612-866-0250
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN04212174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian