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NPI Code Detail

MEDICARE: SUSAN L. PETRY PA

MEDICARE: SUSAN L. PETRY PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant100908NC

General Provider Information

NPI Number : 1518914506
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN L. PETRY PA
Provider Business Mailing Address
First Line : 2501 BLUE RIDGE RD STE 250
Second Line :
City : RALEIGH
State : NC
Zip : 27607-6346
Country : US
Telephone Number : 919-863-4128
Fax Number :
Provider Business Practice Location Address
First Line : 4420 LAKE BOONE TRL
Second Line :
City : RALEIGH
State : NC
Zip : 27607-7505
Country : US
Telephone Number : 919-784-3100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/27/2006
Last Update Date : 02/23/2012

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Directions to “ SUSAN L. PETRY PA” Practice Location

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