Provider Demographics
NPI:1336333509
Name:LARSON-PETERS, SHELLY LEA (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:LEA
Last Name:LARSON-PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LEA
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3601 MINNESOTA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5281
Mailing Address - Country:US
Mailing Address - Phone:612-879-1000
Mailing Address - Fax:612-879-9116
Practice Address - Street 1:11091 ULYSSES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4238
Practice Address - Country:US
Practice Address - Phone:612-879-1000
Practice Address - Fax:612-879-9116
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN508972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology