| Doctor Name: | KATIE MARIE PETERSON |
| NPI Number: | 1508265331 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | AGNP |
| License Number: | AG0614152 |
| Business Practice Address: | 3931 Louisiana Ave S Suite E202 Saint Louis Park, MN - 554265000 |
| Business Phone Number: | 9529939184 |
| Business Fax Number: | |
| Mailing Address: | 2103 Doswell Ave, SAINT PAUL |
| State: | MN |
| Postal Code: | 551081731 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/18/2014 |
| NPI Last Update Date: | 08/18/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LG0600X |
| License Number: | AG0614152 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Gerontology |
| Taxonomy Definition: | |