Provider Demographics
NPI:1265486195
Name:PETRO, JOANNE M (PA C)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:PETRO
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:35 S MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1122
Practice Address - Country:US
Practice Address - Phone:570-474-5847
Practice Address - Fax:570-474-6952
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOA002169363A00000X
PAMA000608L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R06548Medicare UPIN
056148QE7Medicare ID - Type Unspecified