Provider Demographics
NPI:1174794127
Name:PETERSON, BRYANT LEWIS (CRNA)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:LEWIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-432-2600
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:8TH AVE C STREET
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-3350
Practice Address - Fax:770-701-6675
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN37726163W00000X
IDRNA-717367500000X
UT5252922-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1605147Medicare PIN