Provider Demographics
NPI:1336360775
Name:PETEK, MICHAEL R (LMP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:PETEK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 W QUEEN PL
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-5968
Mailing Address - Country:US
Mailing Address - Phone:509-991-3497
Mailing Address - Fax:
Practice Address - Street 1:2918 N ARGONNE RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99212-2150
Practice Address - Country:US
Practice Address - Phone:509-536-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00022186OtherMASSAGE PRACTITIONER