Healthcare Provider Details

I. General information

NPI: 1407913270
Provider Name (Legal Business Name): JACQUELINE ANN PETERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 E 2ND ST
CASPER WY
82601
US

IV. Provider business mailing address

742 S DAVID ST
CASPER WY
82601-3137
US

V. Phone/Fax

Practice location:
  • Phone: 307-577-7201
  • Fax:
Mailing address:
  • Phone: 307-234-9657
  • Fax: 307-234-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036103426
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number42785-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11648A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: