Provider Demographics
NPI:1245363365
Name:PETULA, NATHAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:PETULA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 PROGRESS BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-9053
Mailing Address - Country:US
Mailing Address - Phone:717-532-3211
Mailing Address - Fax:717-532-3099
Practice Address - Street 1:127 WALNUT BOTTOM RD
Practice Address - Street 2:
Practice Address - City:SHIPPENSBURG
Practice Address - State:PA
Practice Address - Zip Code:17257-8131
Practice Address - Country:US
Practice Address - Phone:717-532-3211
Practice Address - Fax:717-532-3099
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP64481Medicare UPIN