Provider Demographics
NPI:1255104683
Name:PETRAS, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:PETRAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 INDIANA 127
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703
Mailing Address - Country:US
Mailing Address - Phone:517-278-2519
Mailing Address - Fax:
Practice Address - Street 1:2655 INDIANA 127
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:517-278-2519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1220-05-6441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist