Healthcare Provider Details

I. General information

NPI: 1669490140
Provider Name (Legal Business Name): LAUREN L PETERSON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7764 FOREST CREEK CT
MAUMEE OH
43537-9140
US

IV. Provider business mailing address

7764 FOREST CREEK CT
MAUMEE OH
43537-9140
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-7652
  • Fax: 419-697-7726
Mailing address:
  • Phone: 419-868-8329
  • Fax: 419-868-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA04744
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN255183
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: