Provider Demographics
NPI:1447241310
Name:PETTRY-HULTMAN, KAREN L (DO)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:L
Last Name:PETTRY-HULTMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 9
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840
Mailing Address - Country:US
Mailing Address - Phone:304-574-2600
Mailing Address - Fax:304-574-2951
Practice Address - Street 1:RR 3 BOX 9
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840
Practice Address - Country:US
Practice Address - Phone:304-574-2600
Practice Address - Fax:304-574-2951
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001714965OtherBC
WV0051304000Medicaid
WVE05962Medicare UPIN
WV001714965OtherBC