Provider Demographics
NPI:1033207642
Name:PETERS, MARY LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 E VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4532
Mailing Address - Country:US
Mailing Address - Phone:206-323-9337
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE STE 1650
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3508
Practice Address - Country:US
Practice Address - Phone:206-464-0873
Practice Address - Fax:206-467-7351
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAC89187Medicare UPIN