Provider Demographics
NPI:1881381994
Name:MARTIN, PETER E (CRNA)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:MARTIN
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 1:400 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:2200 CEDARCREST DR
Practice Address - Street 2:STE B
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868
Practice Address - Country:US
Practice Address - Phone:586-864-6006
Practice Address - Fax:952-442-3620
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122792-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered