Provider Demographics
NPI:1063498830
Name:PETROSKY, MICHAEL KENNETH
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:PETROSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 W KLASKANINE AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 2ND ST SW
Practice Address - Street 2:SUITE 5314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0002
Practice Address - Country:US
Practice Address - Phone:503-861-6155
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other