Provider Demographics
NPI:1497731301
Name:PETITJEAN, SHARON LINDA (MD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LINDA
Last Name:PETITJEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4107 W MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3729
Practice Address - Country:US
Practice Address - Phone:757-251-7977
Practice Address - Fax:757-251-7981
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044063207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE51020Medicare UPIN
VA080185202Medicare PIN
VA015693R82Medicare PIN
VA1497731301Medicaid