Provider Demographics
NPI:1467603266
Name:PETERSEN, JOSEPH D (ARNP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:D
Last Name:PETERSEN
Suffix:
Gender:M
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 808
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0808
Mailing Address - Country:US
Mailing Address - Phone:509-935-6001
Mailing Address - Fax:
Practice Address - Street 1:208 CEDAR CREEK TERRACE
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:WA
Practice Address - Zip Code:99139
Practice Address - Country:US
Practice Address - Phone:509-442-3514
Practice Address - Fax:509-442-3436
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIP60045993363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care