Basic Information
| Provider Information | |||||||||
| NPI: | 1891785606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4029 NORTHWEST AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607520518 | ||||||||
| FaxNumber: | 3606762896 | ||||||||
| Practice Location | |||||||||
| Address1: | 4029 NORTHWEST AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607520518 | ||||||||
| FaxNumber: | 3606762896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 40970 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1021556 | 05 | WA | MEDICAID |