Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | 44049 | MN |
NPI | 1194775429 |
---|---|
Provider Name | Dr. Michael D Peters |
First Address | Maple Grove, MN 55369-4479 |
Second Address | Maple Grove, MN 55369-4479 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 04/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H49124 | (02) |