Provider Demographics
NPI:1801847389
Name:PETERSON, ROBERT W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:PETERSON
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 1:5423 MCQUADE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-3335
Mailing Address - Country:US
Mailing Address - Phone:218-525-1634
Mailing Address - Fax:
Practice Address - Street 1:920 E 1ST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2201
Practice Address - Country:US
Practice Address - Phone:218-279-6211
Practice Address - Fax:218-279-6205
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR069961-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered