Healthcare Provider Details

I. General information

NPI: 1528154770
Provider Name (Legal Business Name): LYUDMILA IVANOVNA PETRUK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

IV. Provider business mailing address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

V. Phone/Fax

Practice location:
  • Phone: 253-596-3410
  • Fax:
Mailing address:
  • Phone: 253-596-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMD27033
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4215
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number21092
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number76532
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD00046499
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: