Provider Demographics
NPI:1013960335
Name:CROSS, PETER W (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:CROSS
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 1:1126 S FEDERAL HWY # 149
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 S FEDERAL HWY
Practice Address - Street 2:#149
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1257
Practice Address - Country:US
Practice Address - Phone:808-292-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN 528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA1011Medicare UPIN
HIH56162Medicare PIN
SCQ345613365Medicare PIN
2618199Medicare ID - Type Unspecified