Provider Demographics
NPI:1851644405
Name:PETERSON, BRAD MICHAEL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:MICHAEL
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 1:4838 E. BASELINE ROAD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4672
Mailing Address - Country:US
Mailing Address - Phone:480-981-2400
Mailing Address - Fax:480-981-2407
Practice Address - Street 1:1900 N HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1604
Practice Address - Country:US
Practice Address - Phone:480-981-2400
Practice Address - Fax:480-981-2407
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0889367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered