Basic Information
| Provider Information | |||||||||
| NPI: | 1457853038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETCH | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3871 E HIGHWAY 98 STE 203 | ||||||||
| Address2: | |||||||||
| City: | PORT ST JOE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324565302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502295661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2018 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9309634 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.