Provider Demographics
NPI:1609323260
Name:PETERSON, MARC ZEPHIRE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ZEPHIRE
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 1:2770 SQUALL KING DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-3304
Mailing Address - Country:US
Mailing Address - Phone:801-870-3968
Mailing Address - Fax:
Practice Address - Street 1:101 CIVIC CENTER LANE
Practice Address - Street 2:HAVASU REGIONAL MEDICAL CENTER
Practice Address - City:LAKE HAVASU
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-505-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-126823-061163W00000X
UT5909731-3102163W00000X
AZCRNA1248367500000X
AZRN202234163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ194923Medicare PIN