Provider Demographics
NPI:1124416334
Name:PETRIE, OLIVIA JEAN WALL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:JEAN WALL
Last Name:PETRIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:JEAN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:114 HERB DIDRICKSON ST
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-7487
Mailing Address - Country:US
Mailing Address - Phone:907-350-2427
Mailing Address - Fax:
Practice Address - Street 1:209 MOLLER AVE
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-7142
Practice Address - Country:US
Practice Address - Phone:907-747-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPADA1224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant