Provider Demographics
NPI:1851721401
Name:PETRIE, JOSEPH W (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:W
Last Name:PETRIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 E. MAIN ST.
Mailing Address - Street 2:#994
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226
Mailing Address - Country:US
Mailing Address - Phone:208-833-1313
Mailing Address - Fax:833-839-1175
Practice Address - Street 1:431 E. MAIN ST.
Practice Address - Street 2:#994
Practice Address - City:CHALLIS
Practice Address - State:ID
Practice Address - Zip Code:83226
Practice Address - Country:US
Practice Address - Phone:208-833-3773
Practice Address - Fax:833-839-1175
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant