Healthcare Provider Details

I. General information

NPI: 1457536302
Provider Name (Legal Business Name): ROBERT BRUCE PETERMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 03/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N EDWARDS ST
ENTERPRISE AL
36330-2510
US

IV. Provider business mailing address

3643 OAK RIDGE LN
DOTHAN AL
36303-8303
US

V. Phone/Fax

Practice location:
  • Phone: 334-347-0584
  • Fax:
Mailing address:
  • Phone: 334-794-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-055052
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: