Provider Demographics
NPI:1629747209
Name:WEYFORTH, PETER JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:WEYFORTH
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 1:1645 W OGDEN AVE UNIT 607
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4382
Mailing Address - Country:US
Mailing Address - Phone:773-294-8813
Mailing Address - Fax:
Practice Address - Street 1:85 E US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8947
Practice Address - Country:US
Practice Address - Phone:219-983-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28256185A390200000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program