Provider Demographics
NPI:1982680666
Name:PETERSEN, AARON M (CRNA)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:M
Last Name:PETERSEN
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 1:3125 DR RUSSELL SMITH WAY
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-7402
Mailing Address - Country:US
Mailing Address - Phone:417-358-8121
Mailing Address - Fax:417-237-7240
Practice Address - Street 1:3125 DR RUSSELL SMITH WAY
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7402
Practice Address - Country:US
Practice Address - Phone:417-358-8121
Practice Address - Fax:417-237-7240
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010327367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200316420AMedicaid
MO35425022OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MO917230708Medicaid
KS200316420AMedicaid
MOW49000004Medicare PIN
KS180055002Medicare PIN
MOW49A00001Medicare PIN