Provider Demographics
NPI:1477540706
Name:PETERSON, NORMA J (CRNA)
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NORMA
Other - Middle Name:J
Other - Last Name:GAULTNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 N MEDICAL DR
Mailing Address - Street 2:JOHN MORAN EYE CENTER UNIVERSITY OF UTAH
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-1000
Mailing Address - Country:US
Mailing Address - Phone:801-587-6635
Mailing Address - Fax:
Practice Address - Street 1:65 N MEDICAL DR
Practice Address - Street 2:JOHN MORAN EYE CENTER UNIVERSITY OF UTAH
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-1000
Practice Address - Country:US
Practice Address - Phone:801-587-6635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR098006028 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210223Medicaid
OR210223Medicaid