Individual
JEFFRY LYNES PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
10117 PINE CREST RD, RED BUD, IL 62278-4458
(618) 282-2872
Mailing address
10117 PINE CREST RD, RED BUD, IL 62278-4458
(270) 898-1922
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
124294
MO
367500000X
Certified Registered Nurse Anesthetist
209-000383
IL
367500000X
Certified Registered Nurse Anesthetist
Primary
3002489
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7424890700
—
KY
Enumeration date
01/31/2007
Last updated
02/04/2020
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