Provider Demographics
NPI:1548296650
Name:PETRIKAS, REGINA M (NP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:PETRIKAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 N GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3436
Mailing Address - Country:US
Mailing Address - Phone:562-420-9950
Mailing Address - Fax:
Practice Address - Street 1:4305 TORRANCE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4400
Practice Address - Country:US
Practice Address - Phone:310-542-9758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9207363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN407621Medicaid
CAWNP9207CMedicare PIN
X35129Medicare UPIN
CARN407621Medicaid