Healthcare Provider Details

I. General information

NPI: 1629078878
Provider Name (Legal Business Name): MICHAEL PETRI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HOSPITAL AVE ANESTHESIA DEPARTMENT
STUART FL
34994-2346
US

IV. Provider business mailing address

421 SE OSCEOLA ST # 3 PO BOX 868
STUART FL
34994-2505
US

V. Phone/Fax

Practice location:
  • Phone: 772-286-0338
  • Fax:
Mailing address:
  • Phone: 772-286-0338
  • Fax: 772-287-1139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number285765
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9263613
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: