Provider Demographics
NPI:1669553723
Name:PETERSON, JON T (DO)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:T
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:4804 SUNSET BEACH DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-867-0595
Mailing Address - Fax:
Practice Address - Street 1:1213 24TH ST STE 100
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2595
Practice Address - Country:US
Practice Address - Phone:360-293-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A1820OtherPREMERA HEALTH
3568326OtherAETNA HMO
50D1031645OtherCLIA
OP00001517OtherWA STATE LICENSE
601371600OtherUS DEPT OF LABOR
A1825OtherPREMERA LIFEWISE
8192247OtherDSHS
A1820OtherPREMERA DIMENSIONS
O186018OtherL & I
2007PEOtherBLUESHIELD FEDERAL
2007PEOtherREGENCE BLUESHIELD
5617199OtherAETNA NON HMO
A1820OtherPREMERA BLUE CROSS
A1820OtherPREMERA BLUE CROSS
A1820OtherPREMERA DIMENSIONS
A1825OtherPREMERA LIFEWISE