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General NPI Number Information
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NPI Number | 1164569729
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Entity Type | Individual
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Provider Name | JEFFRY LYNES PETERSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 05/29/2026
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Provider Practice Location Address
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Address Line | 10117 PINE CREST RD
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City | RED BUD
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State | IL
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Zip | 62278-4458
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Country | US
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Telephone | 618-282-2872
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Fax |
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Provider Business Mailing Address
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Address Line | 10117 PINE CREST RD
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City | RED BUD
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State | IL
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Zip | 62278-4458
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Country | US
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Telephone | 270-898-1922
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 3002489
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 124294
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209-000383
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License Number State | IL
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