Provider Demographics
NPI:1376925974
Name:PETREK, MEAGAN (APRN)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:PETREK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2030 S DITMAR ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6526
Mailing Address - Country:US
Mailing Address - Phone:402-613-3916
Mailing Address - Fax:858-430-3146
Practice Address - Street 1:3900 FIFTH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3122
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-430-3146
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005125363L00000X
CA111821363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner