Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1585 | ND |
N | 225100000X | Physical Therapist | 7998 | MN |
NPI | 1003008525 |
---|---|
Provider Name | Jonathon R Peterson |
First Address | Fargo, ND 58103-4940 |
Second Address | Park Rapids, MN 56470-1440 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2007 |
Last Update Date | 17/03/2018 |