Basic Information
| Provider Information | |||||||||
| NPI: | 1053827832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CAMERON | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 2430 W PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882203553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758874100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2017 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA-01538 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 04536819 | 05 | NM | MEDICAID |