Provider Demographics
NPI:1245730985
Name:PETERSEN, JOSHUA M (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 FENWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-7904
Mailing Address - Country:US
Mailing Address - Phone:206-353-8850
Mailing Address - Fax:
Practice Address - Street 1:342 SW 16TH ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3809
Practice Address - Country:US
Practice Address - Phone:360-807-7235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA608630582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer