Provider Demographics
NPI:1114551108
Name:PETRICH, NAOMI F (PA-C)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:F
Last Name:PETRICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 N ANKENY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4611
Mailing Address - Country:US
Mailing Address - Phone:515-965-4664
Mailing Address - Fax:
Practice Address - Street 1:3625 N ANKENY BLVD STE E
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4611
Practice Address - Country:US
Practice Address - Phone:515-965-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA109585363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant