Provider Demographics
NPI:1841369659
Name:PETKERS, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:PETKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6805
Mailing Address - Country:US
Mailing Address - Phone:207-333-1863
Mailing Address - Fax:
Practice Address - Street 1:690 MINOT AVE STE 2
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-783-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2735OtherLICENSE#