Provider Demographics
NPI:1164569729
Name:PETERSON, JEFFRY LYNES (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:LYNES
Last Name:PETERSON
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 1:10117 PINE CREST RD
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4458
Mailing Address - Country:US
Mailing Address - Phone:270-898-1922
Mailing Address - Fax:
Practice Address - Street 1:10117 PINE CREST RD
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4458
Practice Address - Country:US
Practice Address - Phone:618-282-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO124294367500000X
IL209-000383367500000X
KY3002489367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7424890700Medicaid
KY0397805Medicare UPIN
KYCR03301Medicare PIN