Provider Demographics
NPI:1487689139
Name:PETERSON, JOHN T (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
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 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:
Practice Address - Street 1:150 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1141
Practice Address - Country:US
Practice Address - Phone:304-329-1400
Practice Address - Fax:304-329-1175
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41232163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVR37057Medicare UPIN
WVPE7218971Medicare ID - Type Unspecified