Provider Demographics
NPI:1306898754
Name:PETERSON, ALEXIS JOAN (PA-C)
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:JOAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19685 PILOT KNOB RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-7238
Mailing Address - Country:US
Mailing Address - Phone:651-463-5100
Mailing Address - Fax:
Practice Address - Street 1:19685 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-7238
Practice Address - Country:US
Practice Address - Phone:651-463-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical