Basic Information
| Provider Information | |||||||||
| NPI: | 1811953151 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DEFOREST | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 QUAIL LN | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537716 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | 163W00000X | 0001-161021 | VA | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024-161021 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8934720 | 05 | VA | MEDICAID | 8934495 | 05 | VA | MEDICAID | 8934690 | 05 | VA | MEDICAID | 8934711 | 05 | VA | MEDICAID | 8934703 | 05 | VA | MEDICAID |