Basic Information
| Provider Information | |||||||||
| NPI: | 1598139388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERKA | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W 140TH ST UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528083000 | ||||||||
| FaxNumber: | 9528083001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 W 140TH ST UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528083000 | ||||||||
| FaxNumber: | 9528083001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 13022 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA.0004490 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.