Provider Demographics
NPI:1295268860
Name:PETRO-SAKUMA, JESSICA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PETRO-SAKUMA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-4144
Mailing Address - Country:US
Mailing Address - Phone:785-452-7742
Mailing Address - Fax:785-452-7256
Practice Address - Street 1:400 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4144
Practice Address - Country:US
Practice Address - Phone:785-452-7742
Practice Address - Fax:785-452-7256
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-42891207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201284300AMedicaid