Provider Demographics
NPI:1710917919
Name:PETERSON, EILEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 JOSEPH SIEWICK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3600
Practice Address - Fax:703-391-3414
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024117346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710917919Medicaid
VA1710917919Medicaid
VA430000949Medicare PIN