Healthcare Provider Details

I. General information

NPI: 1528499860
Provider Name (Legal Business Name): CHRISTA MARIE PETKO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTA MARIE PATTERSON

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL CENTER DRIVE
MORGANTOWN WV
26506-8133
US

IV. Provider business mailing address

1 MEDICAL CENTER DRIVE
MORGANTOWN WV
26506-8133
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101309
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN602564
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number73657
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: