Individual
LACIE PETRO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1302 FRANKLIN AVE STE 1100, NORMAL, IL 61761-0016
(309) 268-5620
(309) 661-6226
Mailing address
611 W. PARK ST., FAPC, URBANA, IL 61801
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036119502
IL
207Q00000X
Family Medicine Physician
125-050112
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
833120
MEDICARE GROUP PTAN
IL
Enumeration date
05/03/2007
Last updated
02/12/2021
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