Provider Demographics
NPI:1932336864
Name:PETERSEN, ALLISON WICHMANN (PA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:WICHMANN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:KAY
Other - Last Name:WICHMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST STE 230
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2570
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:952-946-9888
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11606363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633878OtherBCBS PPO
ILP01010061OtherRR MEDICARE
ILT01209Medicare PIN
ILT01208Medicare PIN