Provider Demographics
NPI:1003923582
Name:MICHON, PETER B (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:B
Last Name:MICHON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:920-288-3370
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54308-8900
Practice Address - Country:US
Practice Address - Phone:920-288-3388
Practice Address - Fax:920-288-3370
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN144267-0367500000X
WI153789-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003923582Medicaid