Provider Demographics
NPI:1124022611
Name:PETROSINO, JOSEPH A (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:PETROSINO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2482
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2125 RIVER RD STE 303
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-1135
Practice Address - Country:US
Practice Address - Phone:518-831-2500
Practice Address - Fax:518-831-2510
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004476-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC7079Medicare ID - Type Unspecified
P35785Medicare UPIN