Basic Information
| Provider Information | |||||||||
| NPI: | 1720598014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | KYLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 ROLLING MEADOW LN | ||||||||
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| City: | CLEMMONS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270126744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708429916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 280909 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.