1700932191 NPI number — MRS. CATHERINE MARIE PETRA M.S., A.T.C.

Table of content: MRS. CATHERINE MARIE PETRA M.S., A.T.C. (NPI 1700932191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700932191 NPI number — MRS. CATHERINE MARIE PETRA M.S., A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRA
Provider First Name:
CATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., A.T.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAFOREST
Provider Other First Name:
CATHERINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., A.T.C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700932191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47424 319TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK POINT
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57025-6630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-356-2558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 W 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-0401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-328-1759
Provider Business Practice Location Address Fax Number:
605-328-1857
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0044 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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