Provider Demographics
NPI:1154884138
Name:PETAKOFF, NATHAN WALTER (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:WALTER
Last Name:PETAKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-459-8009
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2803
Practice Address - Country:US
Practice Address - Phone:098-382-5315
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61269644208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist