Provider Demographics
NPI:1891706776
Name:PETERSON, HEIDI JANE (CRNA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JANE
Last Name:PETERSON
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 1:2516 N OZARK AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-4716
Mailing Address - Country:US
Mailing Address - Phone:417-782-8417
Mailing Address - Fax:
Practice Address - Street 1:2516 N OZARK AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-4716
Practice Address - Country:US
Practice Address - Phone:417-782-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01138367500000X
OKR0053014367500000X
MO100802367500000X
KS54629367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100786900AMedicaid
OK200468380NMedicaid
MO500156005Medicaid
MO919696534Medicaid
MO919696567Medicaid
AR152776701Medicaid
OK248630701Medicare PIN
OK100786900AMedicaid
MO500156005Medicaid
MOJ11000002Medicare PIN
OK900522214Medicare PIN
AR5W394Medicare PIN
MO919696567Medicaid
OKP00345773Medicare PIN
OK200468380NMedicaid