Provider Demographics
NPI:1760813570
Name:PETERS, STEPHANIE LINNEA (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LINNEA
Last Name:PETERS
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LINNEA
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA-C
Mailing Address - Street 1:6401 FRANCE AVENUE SOUTH
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2104
Mailing Address - Country:US
Mailing Address - Phone:952-924-5000
Mailing Address - Fax:
Practice Address - Street 1:6401 FRANCE AVE S DEPT OF
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CDR 997338133V00000X
MN12562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered