Provider Demographics
NPI:1356750335
Name:PETIK, ELIZABETH B (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:PETIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:BERNHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:611 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4415
Practice Address - Country:US
Practice Address - Phone:757-283-8300
Practice Address - Fax:757-283-8301
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCO5407363A00000X, 363A00000X
VA0110004798363A00000X
MAPA5339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD517502YWV2Medicare UPIN
MD517555YVZMedicare PIN
VAVVJ054AMedicare PIN
MD517555ZDDBMedicare PIN
VA442611YWAUMedicare PIN