Provider Demographics
NPI:1790803245
Name:PETERS, SUSAN A (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
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 1:3100 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5746
Mailing Address - Country:US
Mailing Address - Phone:907-228-8300
Mailing Address - Fax:907-228-8832
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-8300
Practice Address - Fax:907-228-8832
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7428163W00000X
AK36367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0168686OtherWA L&I
AK6110165OtherAETNA
AKK043ZBBBLBMedicare PIN
AKS08066Medicare UPIN