Provider Demographics
NPI:1821057662
Name:PETERSON, JANE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-1445
Mailing Address - Country:US
Mailing Address - Phone:320-243-3779
Mailing Address - Fax:320-243-7509
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1445
Practice Address - Country:US
Practice Address - Phone:320-243-3779
Practice Address - Fax:320-243-7509
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46218Medicare UPIN