Provider Demographics
NPI:1457323867
Name:PETRARCA, BRIAN D (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:PETRARCA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W NORTHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1324
Mailing Address - Country:US
Mailing Address - Phone:336-275-0927
Mailing Address - Fax:336-275-4834
Practice Address - Street 1:1211 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1313
Practice Address - Country:US
Practice Address - Phone:336-275-0927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCR05960Medicare UPIN
NC203765BMedicare ID - Type Unspecified
FLU62142Medicare ID - Type Unspecified
NC2768773Medicare PIN