MEDICARE: MS. GAYLE MARIE PETERSON 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	367500000X	Certified Registered Nurse Anesthetist	053139	MN

General Provider Information

NPI Number	:	1619936465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GAYLE MARIE PETERSON CRNA

Provider Business Mailing Address
First Line	:	129 HIDDEN FAWN
Second Line	:
City	:	CIBOLO
State	:	TX
Zip	:	78108-4262
Country	:	US
Telephone Number	:	210-658-7299
Fax Number	:

Provider Business Practice Location Address
First Line	:	129 HIDDEN FAWN
Second Line	:
City	:	CIBOLO
State	:	TX
Zip	:	78108-4262
Country	:	US
Telephone Number	:	210-658-7299
Fax Number	:

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	03/10/2010

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