Provider Demographics
NPI:1487991113
Name:PETERSON, COLE WILLIAM (ATC)
Entity type:Individual
Prefix:MR
First Name:COLE
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SNELLING AVE N
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5730
Mailing Address - Country:US
Mailing Address - Phone:612-581-3250
Mailing Address - Fax:612-626-4789
Practice Address - Street 1:1900 SNELLING AVE N
Practice Address - Street 2:
Practice Address - City:FALCON HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55113-5730
Practice Address - Country:US
Practice Address - Phone:612-581-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer