Provider Demographics
NPI:1790776425
Name:PETERSON, LUCY ELIZABETH (MD)
Entity type:Individual
Prefix:MS
First Name:LUCY
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8168
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-0168
Mailing Address - Country:US
Mailing Address - Phone:509-838-3937
Mailing Address - Fax:
Practice Address - Street 1:907 S PERRY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-3462
Practice Address - Country:US
Practice Address - Phone:509-838-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082989A208200000X
WAMD00031440208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1086222Medicaid
WAC87621Medicare UPIN