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General NPI Number Information
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NPI Number | 1003560384
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Entity Type | Individual
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Provider Name | JUSTIN DANIEL PETERSON PT
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Gender | Male
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Dates
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Enumeration Date | 02/07/2022
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Last Update Date | 03/21/2023
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Provider Practice Location Address
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Address Line | 9516 STATE AVE STE B
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City | MARYSVILLE
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State | WA
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Zip | 98270-2277
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Country | US
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Telephone | 360-658-8857
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Fax | 360-659-8296
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Provider Business Mailing Address
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Address Line | 111 TUMWATER BLVD SE STE 113
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City | TUMWATER
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State | WA
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Zip | 98501-6422
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Country | US
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Telephone | 360-528-3300
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Fax | 360-528-8162
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT61183342
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License Number State | WA
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