Basic Information
| Provider Information | |||||||||
| NPI: | 1184177008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERMAN | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4217 NORTHERN PIKE | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151462713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123729100 | ||||||||
| FaxNumber: | 4123726952 | ||||||||
| Practice Location | |||||||||
| Address1: | 4217 NORTHERN PIKE | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151462713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123729100 | ||||||||
| FaxNumber: | 4123726952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 10/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP016301 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 103185270 | 05 | PA | MEDICAID |