Provider Demographics
NPI:1699020461
Name:PETKUS, MAEGAN THERESE (DPT)
Entity Type:Individual
Prefix:
First Name:MAEGAN
Middle Name:THERESE
Last Name:PETKUS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4858 E BASELINE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4638
Mailing Address - Country:US
Mailing Address - Phone:480-807-6500
Mailing Address - Fax:480-897-2700
Practice Address - Street 1:10133 N 92ND ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4556
Practice Address - Country:US
Practice Address - Phone:480-807-6500
Practice Address - Fax:480-897-2700
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1220387225100000X
AZ9864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist