Provider Demographics
NPI:1871620740
Name:CONNOLLY, PETER NELSON (LMP)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:NELSON
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 FRONT ST S
Mailing Address - Street 2:B303
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-4245
Mailing Address - Country:US
Mailing Address - Phone:206-227-6329
Mailing Address - Fax:
Practice Address - Street 1:195 1ST PL NW
Practice Address - Street 2:SUITE 1
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3285
Practice Address - Country:US
Practice Address - Phone:206-227-6329
Practice Address - Fax:425-391-1174
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015725174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist