Provider Demographics
NPI:1356756035
Name:PETRYKOWSKI, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PETRYKOWSKI
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 1:4320 SUMMIT RD SW
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-8879
Mailing Address - Country:US
Mailing Address - Phone:740-973-6413
Mailing Address - Fax:
Practice Address - Street 1:4320 SUMMIT RD SW
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-8879
Practice Address - Country:US
Practice Address - Phone:740-973-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-22
Last Update Date:2014-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103774Medicaid