Provider Demographics
NPI:1548946460
Name:PETERSEN, RICHARD (CRNA)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:PETERSEN
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 1:833 N FRANKLIN ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT SUITE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601
Practice Address - Country:US
Practice Address - Phone:864-455-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC249754163W00000X
SC30415367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse