Healthcare Provider Details

I. General information

NPI: 1932755816
Provider Name (Legal Business Name): MICHAEL PETIKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

IV. Provider business mailing address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1244484
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: