Provider Demographics
NPI:1710525944
Name:PETREY, AARON DEWAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:AARON
Middle Name:DEWAYNE
Last Name:PETREY
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0247
Mailing Address - Country:US
Mailing Address - Phone:423-784-0269
Mailing Address - Fax:423-784-3708
Practice Address - Street 1:475 N HIGHWAY 25 W STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1576
Practice Address - Country:US
Practice Address - Phone:606-549-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2574363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100652600Medicaid
TNQ056813Medicaid