Healthcare Provider Details

I. General information

NPI: 1164569729
Provider Name (Legal Business Name): JEFFRY LYNES PETERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10117 PINE CREST RD
RED BUD IL
62278-4458
US

IV. Provider business mailing address

10117 PINE CREST RD
RED BUD IL
62278-4458
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-2872
  • Fax:
Mailing address:
  • Phone: 270-898-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3002489
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124294
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-000383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: