Provider Demographics
NPI:1881981348
Name:MITEV, PETKO PETKOV (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETKO
Middle Name:PETKOV
Last Name:MITEV
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:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-894-1263
Mailing Address - Fax:888-972-3703
Practice Address - Street 1:695 US HIGHWAY 46
Practice Address - Street 2:SUITE 400A
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1592
Practice Address - Country:US
Practice Address - Phone:973-894-1263
Practice Address - Fax:888-972-3703
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00262400363AS0400X
PAMA054989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ548627YP69Medicare PIN
NJ548630ZJ5NMedicare PIN