Provider Demographics
NPI:1902035934
Name:PETERSON, WYATT (OD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10255 SUMMER PL
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4719
Mailing Address - Country:US
Mailing Address - Phone:612-770-7632
Mailing Address - Fax:
Practice Address - Street 1:10255 SUMMER PL
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-4719
Practice Address - Country:US
Practice Address - Phone:612-770-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist