Basic Information
| Provider Information | |||||||||
| NPI: | 1518914506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 BLUE RIDGE RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198634128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 100908 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.