Healthcare Provider Details

I. General information

NPI: 1467767590
Provider Name (Legal Business Name): SUSAN PETOKAS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S WASHINGTON AVE
SCRANTON PA
18505-1639
US

IV. Provider business mailing address

15 PUBLIC SQ STE 600
WILKES BARRE PA
18701-1704
US

V. Phone/Fax

Practice location:
  • Phone: 570-595-4496
  • Fax: 570-961-3844
Mailing address:
  • Phone: 570-826-1777
  • Fax: 570-823-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP001243B
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP001243B
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007678420050
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier1026041580002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier1007678420035
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier102604158004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 5
Identifier102604158005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: