Provider Demographics
NPI:1982612321
Name:PETERS, ALAN WAYNE
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:WAYNE
Last Name:PETERS
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 1:108 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1641
Mailing Address - Country:US
Mailing Address - Phone:651-345-2318
Mailing Address - Fax:651-345-3310
Practice Address - Street 1:108 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1641
Practice Address - Country:US
Practice Address - Phone:651-345-2318
Practice Address - Fax:651-345-3310
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7548443332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN78628OtherHEALTH PARTNERS
KY6513452318OtherHUMANA GOLD
MN137R7PAOtherBLUE CROSS & BLUE SHIELD
GA6513452318OtherUNITED HEALTH CARE INS
TX82-8229OtherMEDICA CHOICE
MN600708OtherMAYO MANAGMENT SERVICES
WI6513452318OtherWAUSAU INSURANCE COMPANY
MN7121523OtherPREFERRED ONE
MNMN MEDICAIDMedicaid
TX7683462OtherAETNA
MN181341OtherUCARE OF MN
MNHEALTH PARTNERSOtherINSURANCE COMPANY