1710524970 NPI number — SEAN WIBERG PETERSON MS LAT, ATC

Table of content: SEAN WIBERG PETERSON MS LAT, ATC (NPI 1710524970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710524970 NPI number — SEAN WIBERG PETERSON MS LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
SEAN
Provider Middle Name:
WIBERG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710524970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 E 5TH ST APT 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-3809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-590-5397
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 CATLIN AVE
Provider Second Line Business Practice Location Address:
ROOM 1246
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-395-4641
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  3203 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , with the licence number: 2201-39 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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