Provider Demographics
NPI:1891785606
Name:PETERSON, MATTHEW R (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 NORTHWEST AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9077
Mailing Address - Country:US
Mailing Address - Phone:360-752-0518
Mailing Address - Fax:360-676-2896
Practice Address - Street 1:4029 NORTHWEST AVE STE 301
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9077
Practice Address - Country:US
Practice Address - Phone:360-752-0518
Practice Address - Fax:360-676-2896
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA40970207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1021556Medicaid
WA1021556Medicaid
WAG8910442Medicare UPIN