Provider Demographics
NPI:1043561343
Name:PETERSON, BLAKE T (CRNA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:T
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 S 30TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3713
Mailing Address - Country:US
Mailing Address - Phone:509-972-1051
Mailing Address - Fax:509-972-4166
Practice Address - Street 1:406 S 30TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3713
Practice Address - Country:US
Practice Address - Phone:509-972-1051
Practice Address - Fax:509-972-4166
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60300423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered