Provider Demographics
NPI:1073851994
Name:PETKO, CAROLYN MAUREEN (DC)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:MAUREEN
Last Name:PETKO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 BRIDLEWOOD DR S
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-2034
Mailing Address - Country:US
Mailing Address - Phone:716-741-9006
Mailing Address - Fax:716-630-6403
Practice Address - Street 1:6311 BRIDLEWOOD DR S
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-2034
Practice Address - Country:US
Practice Address - Phone:716-741-9006
Practice Address - Fax:716-630-6403
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012308111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor