Glenn Adam Peterson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA61047355 Issued in WA

Practice address

19835 10TH Ave NE Ste B
Poulsbo, WA 98370-7451

Phone

(360) 779-7011

NPI assigned

May 25, 2017

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in IL, WA2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: gpeterson487875@direct.multicare.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Multicare Health System

  dba Multicare Neurological Surgery

  • Neurological Surgery Physician
  • Tacoma, WA
  • NPI 1497766638
  Medicare reassignment
• Tacoma Emergency Care Physicians, PLLC

  • Emergency Medicine Physician
  • Tacoma, WA
  • NPI 1770823791
  Medicare reassignment
• Cepamerica Illinois LLP

  • Emergency Medicine Physician
  • Elgin, IL
  • NPI 1912283110
  Medicare reassignment
• Emergency Services Midwest SC

  • Emergency Medicine Physician
  • Belleville, IL
  • NPI 1174024806
  Medicare reassignment
• Vituity - Illinois Auc LLP

  • Emergency Medicine Physician
  • Effingham, IL
  • NPI 1306334198
  Medicare reassignment
• Multicare Health System

  dba MultiCare Rockwood Imaging

  • Diagnostic Radiology Physician
  • Tacoma, WA
  • NPI 1285121442
  NPD
• Multicare Health System

  dba MultiCare Deaconess Retail Pharmacy

  • Community/Retail Pharmacy
  • Spokane, WA
  • NPI 1396594875
  NPD
• Tacoma Emergency Care Physicians, PLLC

  • Emergency Medicine Physician
  • Tacoma, WA
  • NPI 1073854766
  NPD
• Cepamerica Illinois LLP

  • Emergency Medicine Physician
  • Greenville, IL
  • NPI 1225537137
  NPD
• Cepamerica Illinois LLP

  • Emergency Medicine Physician
  • Springfield, IL
  • NPI 1871360297
  NPD
• Vituity - Illinois Auc LLP

  • Emergency Medicine Physician
  • O'Fallon, IL
  • NPI 1487142022
  NPD
• Multicare Health System

  dba Auburn MultiCare Clinic

  • Family Medicine Physician
  • Auburn, WA
  • NPI 1013969195

  Physician Assistant

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658361600000",
    "number": "1972031698",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "28595 GAMBLE BAY RD NE",
            "city": "KINGSTON",
            "state": "WA",
            "postal_code": "983469503",
            "telephone_number": "618-550-9746"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19835 10TH AVE NE STE B",
            "city": "POULSBO",
            "state": "WA",
            "postal_code": "983707451",
            "telephone_number": "360-779-7011"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "412 S. Jackson St.",
            "address_purpose": "LOCATION",
            "city": "Belleville",
            "state": "IL",
            "postal_code": "62220",
            "country_code": "US",
            "telephone_number": "618-550-9746",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "939 Caroline St",
            "address_purpose": "LOCATION",
            "city": "Port Angeles",
            "state": "WA",
            "postal_code": "983623997",
            "country_code": "US",
            "telephone_number": "360-417-7000",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4500 Memorial Dr",
            "address_purpose": "LOCATION",
            "city": "Belleville",
            "state": "IL",
            "postal_code": "622265360",
            "country_code": "US",
            "telephone_number": "618-233-7750",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "GLENN",
        "middle_name": "ADAM",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-05-25",
        "last_updated": "2022-07-21",
        "certification_date": "2021-05-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085006213",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WA",
            "license": "PA61047355",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peninsula Community Health Services
• Peninsula Community Health Services
• Peninsula Counseling Center LLC
• Peninsula Hearing Inc
• Kimberly Avanngeline Pennybrook, LICSW
• Jeromy A Peterson, DDS PS
• Madeleine Peterson
• Patricia Lynn Pettapiece, D.C.
• Anthony Hoai-Nam Pham, MD
• Riley Phelps, DPT

• Physician Assistant in Poulsbo, WA
• Providers in Poulsbo, WA by specialty
• Physician Assistant in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.