Individual
JERRY R PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4695 SHORELINE DR, SPRING PARK, MN 55384-9715
(952) 442-7890
(952) 442-7893
Mailing address
4695 SHORELINE DR, SPRING PARK, MN 55384-9715
(952) 442-7890
(952) 442-7893
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
20372
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20372
MEDICAL LICENSE
MN
05
—
5093724700
—
MO
Enumeration date
07/21/2005
Last updated
05/12/2008
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