Provider Demographics
NPI:1700492162
Name:PETERSON, ANTHONY DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9203 RASPBERRY CT NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7853
Mailing Address - Country:US
Mailing Address - Phone:651-528-2766
Mailing Address - Fax:
Practice Address - Street 1:619 6TH ST W
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1301
Practice Address - Country:US
Practice Address - Phone:651-528-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist