Provider Demographics
NPI:1649211731
Name:PETERSEN, L DANA (MD)
Entity Type:Individual
Prefix:DR
First Name:L
Middle Name:DANA
Last Name:PETERSEN
Suffix:
Gender:M
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:PO BOX 2
Mailing Address - Street 2:HOLDEN VILLAGE MEDIC
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11155 RAILROAD CREEK VALLEY RD
Practice Address - Street 2:HOLDEN VILLAGE MEDIC
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:360-319-9829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB08970Medicare PIN
WA04894OtherREGENCE BLUESHIELD
WA8924737OtherLABOR & INDUSTRIES (CV)
WA1723105Medicaid
WA423898003OtherGROUP HEALTH COOPERATIVE
WAA09531Medicare UPIN
WA080147956OtherRAILROAD MEDICARE