Provider Demographics
NPI:1972181246
Name:PETERSON, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 WATKINS ST
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1553
Mailing Address - Country:US
Mailing Address - Phone:320-438-4493
Mailing Address - Fax:
Practice Address - Street 1:325 WATKINS ST
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1553
Practice Address - Country:US
Practice Address - Phone:320-438-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver