Provider Demographics
NPI:1467767590
Name:PETOKAS, SUSAN (CRNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETOKAS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PUBLIC SQ STE 600
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1704
Mailing Address - Country:US
Mailing Address - Phone:570-826-1777
Mailing Address - Fax:570-823-3450
Practice Address - Street 1:820 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1639
Practice Address - Country:US
Practice Address - Phone:570-595-4496
Practice Address - Fax:570-961-3844
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP001243B363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007678420050Medicaid
PA1026041580002Medicaid
PA1007678420035Medicaid
PA102604158004Medicaid
PA102604158005Medicaid