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1992706436

NPI Code Detail

MEDICARE: PATRICIA J. PETERSON MD

MEDICARE: PATRICIA J. PETERSON MD

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	207R00000X	Internal Medicine Physician	MD00017283	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	110194835	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	126459	OTHER	WA	LABOR & IND.
5	8923175	OTHER	WA	CRIME VICTIMS

General Provider Information

NPI Number	:	1992706436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA J. PETERSON MD

Provider Business Mailing Address
First Line	:	PO BOX 3002
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-0302
Country	:	US
Telephone Number	:	360-501-3601
Fax Number	:	360-501-3648

Provider Business Practice Location Address
First Line	:	1615 DELAWARE ST
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2367
Country	:	US
Telephone Number	:	360-501-3601
Fax Number	:	360-501-3648

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/30/2012

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Directions to “ PATRICIA J. PETERSON MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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