Provider Demographics
NPI:1619008141
Name:PETALCORIN, JOAN SYBELL (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:SYBELL
Last Name:PETALCORIN
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 1:4214 ANDREWS HWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4817
Mailing Address - Country:US
Mailing Address - Phone:757-963-6507
Mailing Address - Fax:757-963-6375
Practice Address - Street 1:5615 DEAUVILLE STE 240
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2709
Practice Address - Country:US
Practice Address - Phone:432-221-5560
Practice Address - Fax:757-963-6375
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246323208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2005032249OtherMISSOURI TEMP LICENSE
TX518857YPVDOtherTX MEDICARE-PREMIER
KS6310OtherKANSAS TEMPORARY LICENSE
KS6310OtherKANSAS TEMPORARY LICENSE