Provider Demographics
NPI:1245241991
Name:PETRA, ALEXIS (MD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:PETRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3027
Mailing Address - Country:US
Mailing Address - Phone:623-433-6452
Mailing Address - Fax:623-433-6452
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:623-433-6452
Practice Address - Fax:623-433-6452
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30305207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ755043Medicaid
AZ755043Medicaid