Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | DC002109L | PA |
N | 111NR0400X | Rehabilitation Chiropractor | DC002109L | PA |
NPI | 1255352050 |
---|---|
Provider Name | Dr. George Kenneth Petruska |
First Address | Pennsburg, PA 18073-2306 |
Second Address | Pennsburg, PA 18073-2306 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 06/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T72877 | (02) | PA |