Healthcare Provider Details

I. General information

NPI: 1659569341
Provider Name (Legal Business Name): CHAD GARTH PETERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E VAN BUREN ST
PHOENIX AZ
85006-3742
US

IV. Provider business mailing address

1754 E BALSAM PL
CHANDLER AZ
85286-2100
US

V. Phone/Fax

Practice location:
  • Phone: 602-251-8100
  • Fax:
Mailing address:
  • Phone: 480-772-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0617
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: