Basic Information
| Provider Information | |||||||||
| NPI: | 1497852040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | RENNAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 GRANDVIEW CT | ||||||||
| Address2: | |||||||||
| City: | MINNESOTA CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559591209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074940042 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1213 GILMORE AVE | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559872474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074541792 | ||||||||
| FaxNumber: | 5074541793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MN 2563 | MN | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2885 - 035 | WI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 52P81PE | 01 | MN | BCBS | OTHER | 2202971 | 01 | MN | MEDICA | OTHER |