Provider Demographics
NPI:1508942343
Name:PETERSON, COREY REX (CRNA)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:REX
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 1:4478 SPARKLEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4454
Mailing Address - Country:US
Mailing Address - Phone:706-860-7362
Mailing Address - Fax:
Practice Address - Street 1:2260 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4764
Practice Address - Country:US
Practice Address - Phone:706-736-2273
Practice Address - Fax:706-736-7171
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168422367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered