Provider Demographics
NPI:1417840166
Name:PETERSEN, KENDRA
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:PETERSEN
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 1:2211 RIVERSIDE AVENUE SOUTH
Mailing Address - Street 2:CAMPUS BOX 149
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-330-1399
Mailing Address - Fax:612-330-1757
Practice Address - Street 1:2211 RIVERSIDE AVENUE SOUTH
Practice Address - Street 2:CAMPUS BOX 149
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-330-1399
Practice Address - Fax:612-330-1757
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant