Healthcare Provider Details

I. General information

NPI: 1386131324
Provider Name (Legal Business Name): KENNETH D PETERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-8700
  • Fax:
Mailing address:
  • Phone: 920-303-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number198339-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: