Provider Demographics
NPI:1043364722
Name:SHORTT, PEGGY O (ARNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:O
Last Name:SHORTT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-339-5412
Practice Address - Fax:425-259-1164
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005632363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1042641Medicaid
WA9641127Medicaid
WA0202016OtherLABOR AND INDUSTRIES
WA1042641Medicaid
WA9641127Medicaid
WAG8945738Medicare PIN