Basic Information
| Provider Information | |||||||||
| NPI: | 1205190998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | NEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERSH-BURDICK | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | NEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21911 76TH AVE W | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404950 | ||||||||
| FaxNumber: | 4256404958 | ||||||||
| Practice Location | |||||||||
| Address1: | 21911 76TH AVE W | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404950 | ||||||||
| FaxNumber: | 4256404958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ML60293647 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.