Basic Information
| Provider Information | |||||||||
| NPI: | 1366595712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 GRIZZLY LN | ||||||||
| Address2: | |||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563772070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202301585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1526 NORTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202518385 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 043925 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00212663 | 01 | MN | MEDICARE RAILROAD | OTHER |