Healthcare Provider Details

I. General information

NPI: 1992914022
Provider Name (Legal Business Name): RUTH PETROS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S CLARK ST
CARROLL IA
51401-3038
US

IV. Provider business mailing address

311 S CLARK ST
CARROLL IA
51401-3038
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-3581
  • Fax:
Mailing address:
  • Phone: 712-792-3581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number108292
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: