Provider Demographics
NPI:1902826258
Name:PETERSEN, KATHERINE A (CNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2533
Practice Address - Country:US
Practice Address - Phone:651-726-6200
Practice Address - Fax:651-241-0992
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0794675363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500015512OtherRAILROAD MEDICARE
MNP16682Medicare UPIN