Provider Demographics
NPI:1912048737
Name:PETERSON, TIMOTHY M (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
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 1:231 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2744
Mailing Address - Country:US
Mailing Address - Phone:360-563-1020
Mailing Address - Fax:360-563-9040
Practice Address - Street 1:231 AVENUE D
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2744
Practice Address - Country:US
Practice Address - Phone:360-563-1020
Practice Address - Fax:360-563-9040
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8339996Medicaid
WAAB14910Medicare ID - Type Unspecified