Provider Demographics
NPI:1467767590
Name:PETOKAS, SUSAN (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETOKAS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PUBLIC SQ
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1702
Mailing Address - Country:US
Mailing Address - Phone:570-826-1777
Mailing Address - Fax:570-823-3040
Practice Address - Street 1:640 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1631
Practice Address - Country:US
Practice Address - Phone:570-961-5550
Practice Address - Fax:570-961-3844
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP001243B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007678420043Medicaid
PA1026041580002Medicaid
PA1026041580003Medicaid
PA1026041580001Medicaid
PA1026041580002Medicaid