Healthcare Provider Details

I. General information

NPI: 1437101086
Provider Name (Legal Business Name): LAWRENCE CARLTON PETERS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 E MATTHEWS AVE SUITE C
JONESBORO AR
72401-3145
US

IV. Provider business mailing address

2612 HIDDEN HILL CIR
JONESBORO AR
72404-6997
US

V. Phone/Fax

Practice location:
  • Phone: 870-934-8010
  • Fax: 870-934-8010
Mailing address:
  • Phone: 870-935-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00614 CRNA
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: