Provider Demographics
NPI:1912096272
Name:PETERSEN, TRASANDRA A (LMP)
Entity Type:Individual
Prefix:MISS
First Name:TRASANDRA
Middle Name:A
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FAIRVIEW AVE E STE 205
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3727
Mailing Address - Country:US
Mailing Address - Phone:360-878-1633
Mailing Address - Fax:
Practice Address - Street 1:1500 FAIRVIEW AVE E STE 205
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3727
Practice Address - Country:US
Practice Address - Phone:360-878-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0211609OtherDEPT OF L & I