Healthcare Provider Details

I. General information

NPI: 1003103979
Provider Name (Legal Business Name): BRAD PETERSON DVM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOE PETERSON DVM

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8714 N DIVISION ST
SPOKANE WA
99218-1106
US

IV. Provider business mailing address

8714 N DIVISION ST
SPOKANE WA
99218-1106
US

V. Phone/Fax

Practice location:
  • Phone: 509-467-5230
  • Fax: 509-467-1103
Mailing address:
  • Phone: 509-467-5230
  • Fax: 509-467-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3869
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: