Provider Demographics
NPI:1336665736
Name:PETRIE, DOUGLAS PAUL
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PAUL
Last Name:PETRIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8889 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:OZAWKIE
Mailing Address - State:KS
Mailing Address - Zip Code:66070-5096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 S KANSAS AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66612-1332
Practice Address - Country:US
Practice Address - Phone:785-249-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001579171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist