Provider Demographics
NPI:1912970708
Name:LINDBLOOM, PETER JOHN (PA C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:LINDBLOOM
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9314363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-19641OtherMEDICA ISLE
MNHP23883OtherHEALTH PARTNERS
MN551295600Medicaid
MN01-13520OtherMEDICA ONAMIA
MNNA9091033077OtherPREFERRED ONE
410785161002OtherTRICARE CHAMPUS
MN562S8LIOtherBLUE CROSS
MN142458OtherUCARE
ND18358Medicaid
MN01-19641OtherMEDICA ISLE
MN01-13520OtherMEDICA ONAMIA
ND18358Medicaid