Provider Demographics
NPI:1790745792
Name:MIKKELSEN, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:MIKKELSEN
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 1:835 SE BISHOP BLVD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5512
Mailing Address - Country:US
Mailing Address - Phone:509-336-7388
Mailing Address - Fax:509-336-7389
Practice Address - Street 1:835 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5512
Practice Address - Country:US
Practice Address - Phone:509-336-7388
Practice Address - Fax:509-336-7389
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042890207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601704Medicaid
WA1790745792Medicaid
WA1790745792Medicaid