Provider Demographics
NPI:1982756177
Name:PETERSON, ROSS LEKSELL (CRNA)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:LEKSELL
Last Name:PETERSON
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 1:915 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 E 1ST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2201
Practice Address - Country:US
Practice Address - Phone:218-279-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR128433-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered