Provider Demographics
NPI:1447222369
Name:PETERSON, CECILY KAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:CECILY
Middle Name:KAREN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4029 MUIRFIELD LN SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5188
Mailing Address - Country:US
Mailing Address - Phone:360-459-5013
Mailing Address - Fax:253-968-1168
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 REID STREET
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-0208
Practice Address - Fax:253-968-1168
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA12181R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVAD000Medicare UPIN