1477540706 NPI number — NORMA J PETERSON CRNA

Table of content: NORMA J PETERSON CRNA (NPI 1477540706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477540706 NPI number — NORMA J PETERSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
NORMA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAULTNEY
Provider Other First Name:
NORMA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477540706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 N MEDICAL DR
Provider Second Line Business Mailing Address:
JOHN MORAN EYE CENTER UNIVERSITY OF UTAH
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84132-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-6635
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 N MEDICAL DR
Provider Second Line Business Practice Location Address:
JOHN MORAN EYE CENTER UNIVERSITY OF UTAH
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-587-6635
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  098006028 CRNA , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 210223 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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