Provider Demographics
NPI:1710960117
Name:PETERS, KELLY ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:PETERS
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 1:8140 N MOPAC EXPY STE 3-210
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8862
Mailing Address - Country:US
Mailing Address - Phone:512-343-2292
Mailing Address - Fax:512-343-2745
Practice Address - Street 1:8140 N MOPAC EXPY STE 3-210
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8862
Practice Address - Country:US
Practice Address - Phone:512-343-2292
Practice Address - Fax:512-343-2745
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46429367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3358101Medicaid
TX8059UUOtherBLUE CROSS
TX0033581-09Medicaid
TX88678COtherBC/BS
TX8059UUOtherBLUE CROSS
S13339Medicare UPIN
TX0033581-09Medicaid
TX8L11951Medicare PIN