Provider Demographics
NPI:1710985601
Name:PEDEN, ROBERT M III (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:PEDEN
Suffix:III
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 1:1423 PINE VALLEY LOOP
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5216
Mailing Address - Country:US
Mailing Address - Phone:910-964-8203
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-3075
Practice Address - Country:US
Practice Address - Phone:910-907-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC191894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052014Medicaid
NC8052014Medicaid