Basic Information
| Provider Information | |||||||||
| NPI: | 1669490140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7764 FOREST CREEK CT | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435379140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198688329 | ||||||||
| FaxNumber: | 4198688329 | ||||||||
| Practice Location | |||||||||
| Address1: | 7764 FOREST CREEK CT | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435379140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907652 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN255183 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | NA04744 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000519766 | 01 | OH | ANTHEM | OTHER | 2150569 | 05 | OH | MEDICAID | 04097A | 01 | OH | PHC | OTHER | 341881145-003 | 01 | OH | MMO | OTHER | 000000389988 | 01 | OH | ANTHEM | OTHER | P00439234 | 01 | OH | RRMC | OTHER | 5182102 | 05 | MI | MEDICAID |