Provider Demographics
NPI:1669490140
Name:PETERSON, LAUREN L JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:LAUREN
Middle Name:L
Last Name:PETERSON
Suffix:JR
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 1:7764 FOREST CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9140
Mailing Address - Country:US
Mailing Address - Phone:419-868-8329
Mailing Address - Fax:419-868-8329
Practice Address - Street 1:7764 FOREST CREEK CT
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9140
Practice Address - Country:US
Practice Address - Phone:419-690-7652
Practice Address - Fax:419-697-7726
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA04744367500000X
OHRN255183367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04097AOtherPHC
OH000000519766OtherANTHEM
OH341881145-003OtherMMO
OH000000389988OtherANTHEM
OHP00439234OtherRRMC
MI5182102Medicaid
OH2150569Medicaid
OH2150569Medicaid
OHP00439234OtherRRMC