Provider Demographics
NPI:1336464783
Name:PETRO, MARILYN MARTIN (WHNP-RX AUTH)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:MARTIN
Last Name:PETRO
Suffix:
Gender:F
Credentials:WHNP-RX AUTH
Other - Prefix:MRS
Other - First Name:MARTI
Other - Middle Name:
Other - Last Name:PETRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1141 KELLER PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-1627
Mailing Address - Country:US
Mailing Address - Phone:817-741-2601
Mailing Address - Fax:817-745-2601
Practice Address - Street 1:1141 KELLER PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-1627
Practice Address - Country:US
Practice Address - Phone:817-741-2601
Practice Address - Fax:817-745-2601
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685722363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578768701OtherGROUP NPI