Provider Demographics
NPI:1780042036
Name:PETERSON, TYLER JAMES (DC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8470 CITY CENTRE DR STE D
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3356
Mailing Address - Country:US
Mailing Address - Phone:651-571-0726
Mailing Address - Fax:
Practice Address - Street 1:8470 CITY CENTRE DR STE D
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3356
Practice Address - Country:US
Practice Address - Phone:651-571-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor