Provider Demographics
NPI:1346362944
Name:MCPETERS, BRUCE D (CRNA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:MCPETERS
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 1:15118 STARR PL SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9549
Mailing Address - Country:US
Mailing Address - Phone:912-673-6318
Mailing Address - Fax:
Practice Address - Street 1:3209 S 23RD ST
Practice Address - Street 2:STE 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1602
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN096224367500000X
WAAP60202058367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8885529OtherMDCR GRP PTAN
WAG8885530OtherMDCR GRP PTAN (P)
WAG8901039 NASMedicare PIN
WAG8912195SAMedicare PIN