Provider Demographics
NPI:1558669986
Name:PETSCHKE, CAITLEN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAITLEN
Middle Name:M
Last Name:PETSCHKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MED TECH PKWY
Mailing Address - Street 2:STE. 405
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4007
Mailing Address - Country:US
Mailing Address - Phone:423-929-2452
Mailing Address - Fax:423-929-2531
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:STE. 405
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-929-2452
Practice Address - Fax:423-929-2531
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200351363AM0700X
TN2275363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2158848Medicaid