Provider Demographics
NPI:1427887025
Name:PETERSON, MASON ANDREW
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:ANDREW
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 5TH ST NW APT 14
Mailing Address - Street 2:
Mailing Address - City:DILWORTH
Mailing Address - State:MN
Mailing Address - Zip Code:56529-1086
Mailing Address - Country:US
Mailing Address - Phone:701-639-3356
Mailing Address - Fax:
Practice Address - Street 1:201 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1775
Practice Address - Country:US
Practice Address - Phone:701-239-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ND146775376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program