Provider Demographics
NPI:1639398035
Name:PETRUS, PHILIPPE WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILIPPE
Middle Name:WILLIAM
Last Name:PETRUS
Suffix:
Gender:M
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 1:1605 GEORGE DIETER DR STE 636
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5692
Mailing Address - Country:US
Mailing Address - Phone:915-671-1371
Mailing Address - Fax:915-219-9022
Practice Address - Street 1:1900 DENVER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3008
Practice Address - Country:US
Practice Address - Phone:915-544-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03331363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60522321Medicaid
TX203811901Medicaid
NM60522321Medicaid
TX8L15920Medicare PIN
TXQ14421Medicare UPIN