Provider Demographics
NPI:1720368681
Name:PETCA, PERSIDA L (NP-C)
Entity Type:Individual
Prefix:
First Name:PERSIDA
Middle Name:L
Last Name:PETCA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BIG A ROAD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6000
Mailing Address - Country:US
Mailing Address - Phone:706-886-3148
Mailing Address - Fax:706-886-3843
Practice Address - Street 1:58 BIG A ROAD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6000
Practice Address - Country:US
Practice Address - Phone:706-886-3148
Practice Address - Fax:706-886-3843
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA199089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily