Provider Demographics
NPI:1952458978
Name:PETERMAN, JODI L (CRNA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:CEMENSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:8681 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-209-8071
Mailing Address - Fax:651-209-8077
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-735-1870
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1459728367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN050428000Medicaid
MN430005808Medicare PIN