Provider Demographics
NPI:1013003706
Name:PETROSIAN, NOUNE (PAC)
Entity Type:Individual
Prefix:
First Name:NOUNE
Middle Name:
Last Name:PETROSIAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 TENTH STREET
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2343
Mailing Address - Country:US
Mailing Address - Phone:507-372-2921
Mailing Address - Fax:507-372-1815
Practice Address - Street 1:508 TENTH STREET
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2343
Practice Address - Country:US
Practice Address - Phone:507-372-2921
Practice Address - Fax:507-372-1815
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9885363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00314620OtherRR MEDICARE
MN132167OtherUCARE
MN877938400Medicaid
MN970001901Medicare PIN
MN132167OtherUCARE