Individual provider Active NPI

Kyle K Peterson, CRNA

  • Certified Registered Nurse Anesthetist
  • Coon Rapids, MN
National Provider Identifier
1689610818
Registry record updated Mar 30, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
License
R 139340-2 Issued in MN
Practice address
8990 Springbrook Dr NW
Coon Rapids, MN 55433-5850
Phone
(763) 398-0099
Fax
(763) 398-0124
NPI assigned
Jun 22, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 30, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse Anesthetist 367500000X R 139340-2 MN Primary

Addresses

Primary practice location

8990 Springbrook Dr NW
Coon Rapids, MN 55433-5850

Mailing address

8990 Springbrook Dr NW
Coon Rapids, MN 55433-5884
Phone (763) 398-0099

Other identifiers 2

IdentifierTypeStateIssuer
415295600MedicaidMN
05N67PEOtherMNBCBSMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20051013000665 MN Practitioner - Certified Registered Nurse Anesthetist (Crna) 0547174989 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Certified Registered Nurse Anesthetist (Crna)
Education
Other, 2000
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Metropolitan Anesthesia Network LLPGroup PAC ID 5698689123, 516 clinicians

Practice addresses (Care Compare)

8650 Hudson Blvd N
Suite 235
Lake Elmo, MN 55042-8480
Phone (651) 702-7400

Hospital & facility affiliations

  • Mercy Hospital Hospital, Coon Rapids, MN, CCN 240115

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Registered Nurse

State licenses

LicenseStateTypeSpecialty
R 139340-2MNMDCertified Registered Nurse Anesthetist

Practice roles

OrganizationSpecialtyStatusNew patients
Metropolitan Anesthesia Network, LLP Nurse Anesthetist, Certified Registered CurrentSince Sep 1, 2015 Accepting new patients
Anesthesiologist Associates of Hays, PA Past Accepting new patients
Northwest Kansas Pain & Anesthesia, PA Past Accepting new patients

Locations

400 E 3rd St
Duluth, MN 55805
Phone (218) 722-8364

8650 Hudson Blvd N
Ste 235
Lake Elmo, MN 55042
Phone (651) 203-4673

4050 Coon Rapids Blvd NW
Minneapolis, MN 55433
Phone (763) 236-6786

2215 Park Ave
Minneapolis, MN 55404
Phone (612) 775-8800

8100 Northland Dr
Minneapolis, MN 55431
Phone (952) 831-1626

1100 Bergslien St
Baldwin, WI 54002
Phone (715) 684-1111

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150934400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1269907200000",
    "number": "1689610818",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8990 SPRINGBROOK DR NW",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554335884",
            "telephone_number": "763-398-0099",
            "fax_number": "763-398-0124"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8990 SPRINGBROOK DR NW",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554335850",
            "telephone_number": "763-398-0099",
            "fax_number": "763-398-0124"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "KYLE",
        "middle_name": "K",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-22",
        "last_updated": "2010-03-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "MN",
            "license": "R 139340-2",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "415295600",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSMN",
            "identifier": "05N67PE",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Coon Rapids, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 30, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.