Basic Information
| Provider Information | |||||||||
| NPI: | 1083134019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | BERNS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1148 BROADWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537221539 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1708 E 44TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537222161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LP04110 | RI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD17011 | RI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD61181360 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | LP04110 | 01 | RI | RHODE ISLAND STATE MEDICAL LICENSE | OTHER |