Provider Demographics
NPI:1740878669
Name:PETKUS, DAVID JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOSEPH
Last Name:PETKUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PARK LN
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1439
Mailing Address - Country:US
Mailing Address - Phone:517-270-0951
Mailing Address - Fax:
Practice Address - Street 1:1526 MARTIN ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-3058
Practice Address - Country:US
Practice Address - Phone:814-237-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant