Healthcare Provider Details

I. General information

NPI: 1619479797
Provider Name (Legal Business Name): PETERSON NGUYEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST FL 11
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

22 S GREENE ST FL 11
BALTIMORE MD
21201-1544
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1616
  • Fax: 562-242-7704
Mailing address:
  • Phone: 667-214-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR217862
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR217862
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: