Provider Demographics
NPI:1316999279
Name:PETERSON, WANIQUE ANNE
Entity type:Individual
Prefix:
First Name:WANIQUE
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WANIQUE
Other - Middle Name:ANNE
Other - Last Name:EVENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2302 E HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-3152
Mailing Address - Country:US
Mailing Address - Phone:320-269-5000
Mailing Address - Fax:320-269-3030
Practice Address - Street 1:2302 E HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-3152
Practice Address - Country:US
Practice Address - Phone:320-269-5000
Practice Address - Fax:320-269-3030
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3676111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN405018500Medicaid
MN84G86WEOtherBLUE CROSS BLUE SHEILD
MN405018500Medicaid
MN84G86WEOtherBLUE CROSS BLUE SHEILD