=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811003239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES JOHN PETERFESO CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 BAY PINES BLVD
-----------------------------------------------------
City | BAY PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-398-6661
-----------------------------------------------------
Fax | 727-319-1049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 7TH ST N UNIT 13
-----------------------------------------------------
City | BRADENTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34217-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-778-3857
-----------------------------------------------------
Fax | 727-391-1049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R104309-5
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------