Provider Demographics
NPI:1851631907
Name:PETERSEN, GREGORY JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOSEPH
Last Name:PETERSEN
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 1:9505 BLACKOAKS LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1229
Mailing Address - Country:US
Mailing Address - Phone:763-420-4111
Mailing Address - Fax:763-420-4145
Practice Address - Street 1:9505 BLACKOAKS LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1229
Practice Address - Country:US
Practice Address - Phone:763-420-4111
Practice Address - Fax:763-420-4145
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor