Provider Demographics
NPI:1720165160
Name:PETERSON, LYNN A (MSN, CRNA)
Entity Type:Individual
Prefix:MR
First Name:LYNN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 S JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-1421
Mailing Address - Country:US
Mailing Address - Phone:509-220-3834
Mailing Address - Fax:
Practice Address - Street 1:714 W PINE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9046
Practice Address - Country:US
Practice Address - Phone:509-447-2441
Practice Address - Fax:509-447-2281
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006221367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000381050OtherMEDICARE GROUP NUMBER
WAP00395894OtherMEDICARE RAILROAD
WACG4026OtherRAILROAD GROUP NUMBER
WA9636465Medicaid
WAG8807877Medicare PIN