Healthcare Provider Details

I. General information

NPI: 1982756177
Provider Name (Legal Business Name): ROSS LEKSELL PETERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E 1ST ST SUITE 101
DULUTH MN
55805-2201
US

IV. Provider business mailing address

915 E 1ST ST
DULUTH MN
55805-2107
US

V. Phone/Fax

Practice location:
  • Phone: 218-279-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR128433-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: