Provider Demographics
NPI:1932560067
Name:PETERSON, TINA LYNN LOUIE (CRNA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LYNN LOUIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:LYNN LOUIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:505 NE 87TH AVE
Mailing Address - Street 2:SUITE 46.5
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1989
Mailing Address - Country:US
Mailing Address - Phone:360-828-5396
Mailing Address - Fax:360-828-5455
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:SUITE 46.5
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-828-5396
Practice Address - Fax:360-828-5455
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60637603367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered