Provider Demographics
NPI:1114070455
Name:PETERSON, TATIANA LVOVNA (MD)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:LVOVNA
Last Name:PETERSON
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 1:2121 NE 139TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2316
Mailing Address - Country:US
Mailing Address - Phone:360-487-1000
Mailing Address - Fax:360-487-5239
Practice Address - Street 1:2121 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2316
Practice Address - Country:US
Practice Address - Phone:360-487-1000
Practice Address - Fax:360-487-5239
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8374563Medicaid
WA8374563Medicaid
I20831Medicare UPIN