Provider Demographics
NPI:1174766505
Name:PETERSON, ERIK JORDAN (MD)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:JORDAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5130 FAIRVIEW BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8050
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:5130 FAIRVIEW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8050
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62173-20207X00000X
MN57620207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery