Individual
SHANE PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
325 WATKINS ST, MORA, MN 55051-1553
(320) 438-4493
Mailing address
325 WATKINS ST, MORA, MN 55051-1553
(320) 438-4493
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Enumeration date
03/30/2021
Last updated
03/30/2021
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