Provider Demographics
NPI:1861450397
Name:WARREN, PETRA K (MD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:K
Last Name:WARREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:230 S ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29323-1504
Practice Address - Country:US
Practice Address - Phone:864-461-4951
Practice Address - Fax:864-461-4956
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT63044Medicaid
SCP010990007OtherRAILROAD MEDICARE
SCC434863365Medicare PIN
SCP010990007OtherRAILROAD MEDICARE
SCC43486Medicare UPIN