Provider Demographics
NPI:1700250735
Name:PETERSON, DANE (PT)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:503-443-6156
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:14028 SE PETROVITSKY RD
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8933
Practice Address - Country:US
Practice Address - Phone:425-272-0252
Practice Address - Fax:425-272-0291
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60599956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0349712OtherWA L&I
WA1700250735Medicaid
WA0349712OtherWA L&I