Provider Demographics
NPI:1477841997
Name:PETERSON, CAMPBELL SHARPE (CRNA)
Entity type:Individual
Prefix:MS
First Name:CAMPBELL
Middle Name:SHARPE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:CAMPBELL
Other - Middle Name:DORIS
Other - Last Name:SHARPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1450 WESTERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3539
Mailing Address - Country:US
Mailing Address - Phone:919-271-9856
Mailing Address - Fax:
Practice Address - Street 1:1450 WESTERN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3539
Practice Address - Country:US
Practice Address - Phone:919-271-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713311367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered