Provider Demographics
NPI:1184058570
Name:BIRD, PRESTON PETERSON (CRNA)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:PETERSON
Last Name:BIRD
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:PO BOX 94645
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6945
Mailing Address - Country:US
Mailing Address - Phone:509-474-6842
Mailing Address - Fax:509-474-6606
Practice Address - Street 1:170 N 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2096
Practice Address - Country:US
Practice Address - Phone:801-492-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6445536-4406367500000X
WAAP60404208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered