Provider Demographics
NPI:1134769979
Name:PETERSON, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
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 1:4314 45TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-6915
Mailing Address - Country:US
Mailing Address - Phone:701-850-9229
Mailing Address - Fax:
Practice Address - Street 1:4314 45TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-6915
Practice Address - Country:US
Practice Address - Phone:701-850-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1468840Medicaid