Healthcare Provider Details

I. General information

NPI: 1932284460
Provider Name (Legal Business Name): KRIS ALLEN PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 BRIDGEPORT WAY SW STE 2
LAKEWOOD WA
98499-2449
US

IV. Provider business mailing address

9115 BRIDGEPORT WAY SW STE 2
LAKEWOOD WA
98499-2449
US

V. Phone/Fax

Practice location:
  • Phone: 253-393-9099
  • Fax: 253-393-9098
Mailing address:
  • Phone: 253-393-9099
  • Fax: 253-393-9098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00031307
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00031307
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: