Provider Demographics
NPI:1902805518
Name:PETERSON, PAUL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHARLES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-255-7891
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-255-7891
Practice Address - Fax:320-255-5882
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300395207P00000X, 2084S0012X, 2084V0102X
MN648512084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH29767Medicare UPIN