Provider Demographics
NPI:1841274255
Name:PETERSEN, DALE R
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:R
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 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-993-6450
Mailing Address - Fax:952-993-0300
Practice Address - Street 1:2001 BLAISDELL AVE
Practice Address - Street 2:PARK NICOLLET CLINIC MINNEAPOLIS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2414
Practice Address - Country:US
Practice Address - Phone:952-993-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN728595700Medicaid
MN110001068Medicare ID - Type Unspecified
MN728595700Medicaid