Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 3139 | AZ |
N | 2251G0304X | Physical Therapist - Geriatrics | 3139 | AZ |
N | 2251N0400X | Physical Therapist - Neurology | 3139 | AZ |
N | 2251X0800X | Physical Therapist - Orthopedic | 3139 | AZ |
NPI | 1467769364 |
---|---|
Provider Name | Colleen Marie Petras |
First Address | Phoenix, AZ 85048-9181 |
Second Address | Phoenix, AZ 85048-9181 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2010 |
Last Update Date | 13/09/2010 |