Provider Demographics
NPI:1972031698
Name:PETERSON, GLENN ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ADAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28595 GAMBLE BAY RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9503
Mailing Address - Country:US
Mailing Address - Phone:618-550-9746
Mailing Address - Fax:
Practice Address - Street 1:19835 10TH AVE NE STE B
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7451
Practice Address - Country:US
Practice Address - Phone:360-779-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006213363A00000X
363A00000X
WAPA61047355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant