Provider Demographics
NPI:1114913662
Name:CLEVELAND-PECK, CHRISTIAN MICHAEL (CRNA)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:MICHAEL
Last Name:CLEVELAND-PECK
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 1:531 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-2817
Mailing Address - Country:US
Mailing Address - Phone:727-821-5292
Mailing Address - Fax:727-821-5292
Practice Address - Street 1:531 24TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-2817
Practice Address - Country:US
Practice Address - Phone:727-821-5292
Practice Address - Fax:727-821-5292
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3169412367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304609500Medicaid
FLG3186OtherBCBS
Y1133VMedicare PIN
FLY1133XMedicare ID - Type Unspecified