Provider Demographics
NPI:1962423392
Name:PETROK, KAREN MARIE (APRN)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:PETROK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415126
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-0001
Mailing Address - Country:US
Mailing Address - Phone:203-384-3394
Mailing Address - Fax:203-384-3829
Practice Address - Street 1:226 MILL HILL AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2826
Practice Address - Country:US
Practice Address - Phone:203-384-3394
Practice Address - Fax:203-384-3829
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001573363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004188779Medicaid
CT004188779Medicaid
CT500001237Medicare PIN