Provider Demographics
NPI:1235103284
Name:PETERSON, RONDA K (ATC)
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4102
Mailing Address - Country:US
Mailing Address - Phone:218-287-1270
Mailing Address - Fax:
Practice Address - Street 1:125 NEMZEK
Practice Address - Street 2:MSUM
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563
Practice Address - Country:US
Practice Address - Phone:218-477-2626
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer