Provider Demographics
NPI:1528499860
Name:PETKO, CHRISTA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:MARIE
Last Name:PETKO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHRISTA
Other - Middle Name:MARIE
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-8133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-8133
Practice Address - Country:US
Practice Address - Phone:304-598-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101309367500000X
PARN602564390200000X
WV73657390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program