MEDICARE: MISS TRASANDRA A PETERSEN LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00022813	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0211609	OTHER	WA	DEPT OF L & I

General Provider Information

NPI Number	:	1912096272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TRASANDRA A PETERSEN LMP

Provider Business Mailing Address
First Line	:	1500 FAIRVIEW AVE E STE 205
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102-3727
Country	:	US
Telephone Number	:	360-878-1633
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 FAIRVIEW AVE E STE 205
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102-3727
Country	:	US
Telephone Number	:	360-878-1633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	11/17/2017

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