Healthcare Provider Details

I. General information

NPI: 1245984566
Provider Name (Legal Business Name): NEAL MICHAEL PETERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1396
US

IV. Provider business mailing address

3327 N CASALOMA DR UNIT 172
APPLETON WI
54913-7968
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax:
Mailing address:
  • Phone: 715-340-6399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226904-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number138682
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: