Basic Information
| Provider Information | |||||||||
| NPI: | 1982680666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173588121 | ||||||||
| FaxNumber: | 4172377240 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173588121 | ||||||||
| FaxNumber: | 4172377240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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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 | 2008010327 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200316420A | 05 | KS | MEDICAID | 35425022 | 01 | MO | BLUE CROSS BLUE SHIELD OF KANSAS CITY | OTHER | 917230708 | 05 | MO | MEDICAID |