Provider Demographics
NPI:1669244273
Name:PETERSEN, MEGAN (ATC)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1754 110TH AVE
Mailing Address - Street 2:
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-4011
Mailing Address - Country:US
Mailing Address - Phone:507-329-3818
Mailing Address - Fax:
Practice Address - Street 1:600 W COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1060
Practice Address - Country:US
Practice Address - Phone:605-997-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD06032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer