Provider Demographics
NPI:1538302021
Name:MCEWAN, PETRA KAYE (MD)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:KAYE
Last Name:MCEWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:KAYE
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1500 NW 63RD WAY
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-2605
Mailing Address - Country:US
Mailing Address - Phone:954-778-3744
Mailing Address - Fax:250-999-6241
Practice Address - Street 1:9868 S STATE ROAD 7 STE 305
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4475
Practice Address - Country:US
Practice Address - Phone:954-778-3744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
FLME112066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005456700Medicaid