Provider Demographics
NPI:1841765864
Name:PETERSON, TOD C
Entity type:Individual
Prefix:
First Name:TOD
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
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 871327
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-1327
Mailing Address - Country:US
Mailing Address - Phone:360-605-2350
Mailing Address - Fax:360-991-0010
Practice Address - Street 1:8807 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2532
Practice Address - Country:US
Practice Address - Phone:360-605-2350
Practice Address - Fax:360-991-0010
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60877646363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health