Provider Demographics
NPI:1225667736
Name:PETROSYAN, NINA (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PETROSYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:OFFICE OF STUDENT AFFAIRS 1975 ZONAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6070
Practice Address - Country:US
Practice Address - Phone:970-810-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COTL.0008739390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program