=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619008141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN SYBELL PETALCORIN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5615 DEAUVILLE STE 240
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79706-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-221-5560
-----------------------------------------------------
Fax | 757-963-6375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4214 ANDREWS HWY STE 240
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79703-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-963-6507
-----------------------------------------------------
Fax | 757-963-6375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 0101246323
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------