1669553723 NPI number — MR. JON T PETERSON DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669553723 NPI number — MR. JON T PETERSON DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PETERSON

Provider First Name:

JON

Provider Middle Name:

T

Provider Name Prefix Text:

MR.

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1669553723

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

4804 SUNSET BEACH DRIVE NW

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

OLYMPIA

Provider Business Mailing Address State Name:

WA

Provider Business Mailing Address Postal Code:

98502

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

360-867-0595

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1213 24TH ST STE 100

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ANACORTES

Provider Business Practice Location Address State Name:

WA

Provider Business Practice Location Address Postal Code:

98221-2595

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

360-293-3101

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/17/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  OP00001517 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: A1820 . This is a "PREMERA HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 3568326 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
• Identifier: 50D1031645 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
• Identifier: OP00001517 . This is a "WA STATE LICENSE" identifier . This identifiers is of the category "OTHER".
• Identifier: 601371600 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
• Identifier: A1825 . This is a "PREMERA LIFEWISE" identifier . This identifiers is of the category "OTHER".
• Identifier: 8192247 . This is a "DSHS" identifier . This identifiers is of the category "OTHER".
• Identifier: A1820 . This is a "PREMERA DIMENSIONS" identifier . This identifiers is of the category "OTHER".
• Identifier: O186018 . This is a "L & I" identifier . This identifiers is of the category "OTHER".
• Identifier: 2007PE . This is a "BLUESHIELD FEDERAL" identifier . This identifiers is of the category "OTHER".
• Identifier: 2007PE . This is a "REGENCE BLUESHIELD" identifier . This identifiers is of the category "OTHER".
• Identifier: 5617199 . This is a "AETNA NON HMO" identifier . This identifiers is of the category "OTHER".
• Identifier: A1820 . This is a "PREMERA BLUE CROSS" identifier . This identifiers is of the category "OTHER".