Provider Demographics
NPI:1336184811
Name:PETRAKIS, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PETRAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS301817OtherHPK
KS4635OtherPHS
KS100191130DMedicaid
KS102871OtherBCBS
KS167528OtherCOVENTRY
KS100191130DMedicaid