Provider Demographics
NPI:1295181097
Name:PETERSEN, MARK (PT,DPT,OCS,ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PT,DPT,OCS,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PLATTE
Mailing Address - State:SD
Mailing Address - Zip Code:57369-2123
Mailing Address - Country:US
Mailing Address - Phone:605-337-3364
Mailing Address - Fax:605-337-2670
Practice Address - Street 1:601 E 7TH ST
Practice Address - Street 2:
Practice Address - City:PLATTE
Practice Address - State:SD
Practice Address - Zip Code:57369-2123
Practice Address - Country:US
Practice Address - Phone:605-337-3364
Practice Address - Fax:605-337-2670
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1185225100000X
MN8730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist