Basic Information
| Provider Information | |||||||||
| NPI: | 1699269308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRE | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 46TH AVE | ||||||||
| Address2: | |||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097962329 | ||||||||
| FaxNumber: | 3097961146 | ||||||||
| Practice Location | |||||||||
| Address1: | 1285 HARTREY AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602021056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476663494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2018 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125.072248 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.