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General NPI Number Information
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NPI Number | 1609323260
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Entity Type | Individual
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Provider Name | MARC ZEPHIRE PETERSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 11/08/2016
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Provider Practice Location Address
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Address Line | 101 CIVIC CENTER LANE HAVASU REGIONAL MEDICAL CENTER
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City | LAKE HAVASU
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State | AZ
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Zip | 86403
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Country | US
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Telephone | 928-505-5760
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Fax |
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Provider Business Mailing Address
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Address Line | 2770 SQUALL KING DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86404-3304
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Country | US
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Telephone | 801-870-3968
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 14-126823-061
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 5909731-3102
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License Number State | UT
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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 | CRNA1248
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN202234
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License Number State | AZ
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