Provider Demographics
NPI:1669430062
Name:LANDRY, PETER ALBERT (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALBERT
Last Name:LANDRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19449 EVANS ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1074
Mailing Address - Country:US
Mailing Address - Phone:612-702-9012
Mailing Address - Fax:763-633-0039
Practice Address - Street 1:19449 EVANS ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1074
Practice Address - Country:US
Practice Address - Phone:612-702-9012
Practice Address - Fax:763-633-0039
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN94631OtherHEALTH PARTNERS GROUP NUM
MN45D48LAOtherBLUECROSS PIN
MN4487073OtherMEDICA GROUP ID
MN45D48LAOtherBLUECROSS PIN