Healthcare Provider Details

I. General information

NPI: 1447222369
Provider Name (Legal Business Name): CECILY KAREN PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 REID STREET
TACOMA WA
98431-0001
US

IV. Provider business mailing address

4029 MUIRFIELD LN SE
OLYMPIA WA
98501-5188
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0208
  • Fax: 253-968-1168
Mailing address:
  • Phone: 360-459-5013
  • Fax: 253-968-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12181R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: