Provider Demographics
NPI:1114271392
Name:SCHUPP, PETER JOSEPH (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOSEPH
Last Name:SCHUPP
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 1:5025 AIRPORT CENTER PKWY BLDG L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5885
Mailing Address - Country:US
Mailing Address - Phone:704-512-7105
Mailing Address - Fax:
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-384-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC216289367500000X
NC091003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered