MEDICARE: PHILIPPE WILLIAM PETRUS PA-C

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
1	363A00000X	Physician Assistant	PA03331	TX
2	363AM0700X	Medical Physician Assistant	PA03331	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639398035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIPPE WILLIAM PETRUS PA-C

Provider Business Mailing Address
First Line	:	1605 GEORGE DIETER DR STE 636
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-5692
Country	:	US
Telephone Number	:	915-671-1371
Fax Number	:	915-219-9022

Provider Business Practice Location Address
First Line	:	1900 DENVER AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79902-3008
Country	:	US
Telephone Number	:	915-544-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	08/08/2025

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