Provider Demographics
NPI:1992706436
Name:PETERSON, PATRICIA J (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
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 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-501-3601
Mailing Address - Fax:360-501-3648
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-501-3601
Practice Address - Fax:360-501-3648
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218636Medicaid
WA8239071Medicaid
WA126459OtherLABOR & IND.
110194835OtherRR MEDICARE
WA8923175OtherCRIME VICTIMS
WA126459OtherLABOR & IND.
A54885Medicare UPIN
OR218636Medicaid