Provider Demographics
NPI:1134636251
Name:PETROFF, DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PETROFF
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 1:9 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2318
Mailing Address - Country:US
Mailing Address - Phone:315-560-0830
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-560-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant