Basic Information
| Provider Information | |||||||||
| NPI: | 1932560067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LYNN LOUIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | LYNN LOUIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 505 NE 87TH AVE | ||||||||
| Address2: | SUITE 46.5 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608285396 | ||||||||
| FaxNumber: | 3608285455 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 NE 87TH AVE | ||||||||
| Address2: | SUITE 46.5 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608285396 | ||||||||
| FaxNumber: | 3608285455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2016 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP60637603 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.