Provider Demographics
NPI:1093807281
Name:PETRAS, MARY JO (MA CCCA FAAA)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:PETRAS
Suffix:
Gender:F
Credentials:MA CCCA FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 TALON DRIVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414
Mailing Address - Country:US
Mailing Address - Phone:307-587-0343
Mailing Address - Fax:
Practice Address - Street 1:721 SHERIDAN AVE
Practice Address - Street 2:SUITE 150 BIG HORN BASIN HEARING INC
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414
Practice Address - Country:US
Practice Address - Phone:307-527-6475
Practice Address - Fax:307-527-6483
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYAUDIOLOGY A966231H00000X
WYAUDIOLOGIST HEARING237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1179837000Medicaid
WY1179837000Medicaid