Provider Demographics
NPI:1164467783
Name:EGGERT, PETRA A (DC PT)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:A
Last Name:EGGERT
Suffix:
Gender:F
Credentials:DC PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21040 HOMESTEAD RD STE 202A
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0238
Mailing Address - Country:US
Mailing Address - Phone:408-530-0005
Mailing Address - Fax:408-530-9473
Practice Address - Street 1:21040 HOMESTEAD RD STE 202A
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0238
Practice Address - Country:US
Practice Address - Phone:408-530-0005
Practice Address - Fax:408-530-9473
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14818225100000X
CA24118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0241180OtherBLUE SHIELD PIN
CA0PT148180Medicare PIN
CABX659AMedicare PIN
CABX659ZMedicare PIN
CA0PT148181Medicare PIN
CAU73332Medicare UPIN
CADC0241180Medicare PIN