Healthcare Provider Details

I. General information

NPI: 1790745792
Provider Name (Legal Business Name): PETER M MIKKELSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 SE BISHOP BLVD
PULLMAN WA
99163-5512
US

IV. Provider business mailing address

835 SE BISHOP BLVD
PULLMAN WA
99163-5512
US

V. Phone/Fax

Practice location:
  • Phone: 509-336-7388
  • Fax: 509-336-7389
Mailing address:
  • Phone: 509-336-7388
  • Fax: 509-336-7389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00042890
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1790745792
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier1019013
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier500601704
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: