Basic Information
Provider Information
NPI: 1003804147
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERSON
FirstName: STEVEN
MiddleName: K.
NamePrefix: MR.
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1236 E ELIZABETH ST
Address2: SUITE 1
City: FORT COLLINS
State: CO
PostalCode: 805244000
CountryCode: US
TelephoneNumber: 9702242985
FaxNumber: 9704729381
Practice Location
Address1: 1236 E ELIZABETH ST
Address2: SUITE 1
City: FORT COLLINS
State: CO
PostalCode: 805244000
CountryCode: US
TelephoneNumber: 9702242985
FaxNumber: 9704729381
Other Information
ProviderEnumerationDate: 10/12/2005
LastUpdateDate: 07/14/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000XCRA-1218COY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 
367500000X81449CON Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
10899430005WY MEDICAID
0781449405CO MEDICAID


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