MEDICARE: CLINTON PETERMAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN000177585	TN
2	367500000X	Certified Registered Nurse Anesthetist	22180	TN

General Provider Information

NPI Number	:	1588108328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON PETERMAN CRNA

Provider Business Mailing Address
First Line	:	1019 RIVER BEND DR
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-5975
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019 RIVER BEND DR
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-5975
Country	:	US
Telephone Number	:	931-397-5724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2016
Last Update Date	:	07/19/2017

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