Provider Demographics
NPI:1508390519
Name:PETERSEN ANESTHESIA SERVICES
Entity Type:Organization
Organization Name:PETERSEN ANESTHESIA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-244-1756
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-0112
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:5085 PARK RD
Practice Address - Street 2:SUITE 180B
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2593
Practice Address - Country:US
Practice Address - Phone:713-812-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty