KEITH E PETERSEN (DO) – Adult Medicine Physician, NPI 1356615470
Adult Medicine Physician
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
4,141 FAMILY PRACTICE in WA
Provider Addresses for KEITH E PETERSEN (DO)
9040 JACKSON AVE
TACOMA, WA 984311000
Phone: (253) 968-1340
Type: Location
9040 JACKSON AVE 9040 JACKSON STREET
TACOMA, WA 984311000
Phone: (253) 968-1340
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2017-05-29
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20170529000058 | I | Family Practice | WA | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 98431)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Physician Assistant | WA | |
| Nurse Practitioner | WA | |
| - | IL | |
| O P H T H A L M O L O G Y | OR | |
| Nurse Practitioner | TN | |
| Nurse Practitioner | WA | |
| Nurse Practitioner | WA | |
| Family Practice | WA | |
| Interventional Radiology, Diagnostic Radiology | OH | |
| Physician Assistant | ID |
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