Provider Demographics
NPI:1679545750
Name:PETNER, GARY (PA-C)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PETNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 TORRESDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-1915
Mailing Address - Country:US
Mailing Address - Phone:215-605-5465
Mailing Address - Fax:
Practice Address - Street 1:2757 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2700
Practice Address - Country:US
Practice Address - Phone:215-839-9661
Practice Address - Fax:215-309-3533
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00106100363A00000X
PAMA051206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ071672RLEMedicare ID - Type Unspecified
PAP94033Medicare UPIN
PA072025Medicare ID - Type Unspecified