Provider Demographics
NPI:1154513117
Name:PETRYCKI, JOHANNA (PA)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:PETRYCKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 228
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-265-1351
Mailing Address - Fax:631-265-9363
Practice Address - Street 1:222 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 228
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-265-1351
Practice Address - Fax:631-265-9363
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1154513117OtherNPI
NY012251-1OtherLICENSE