Provider Demographics
NPI:1255077202
Name:PETERSON, AMANDA VANCENE (AGACNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VANCENE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:AGACNP
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:612-262-4400
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N STE 501
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2545
Practice Address - Country:US
Practice Address - Phone:651-726-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1750728163WC0200X
MN00000363LA2100X
MN9286363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine