Provider Demographics
NPI:1154334704
Name:PETTA, MARIA T (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:T
Last Name:PETTA
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 1:2950 CLEVELAND CLINIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3609
Mailing Address - Country:US
Mailing Address - Phone:954-659-5290
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3609
Practice Address - Country:US
Practice Address - Phone:954-659-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101530363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291096900Medicaid
FLP63376Medicare UPIN
FLE6364YMedicare ID - Type Unspecified
FLE6364VMedicare ID - Type Unspecified
FLE6364ZMedicare ID - Type Unspecified
FLE6364TMedicare ID - Type Unspecified
FL291096900Medicaid