Provider Demographics
NPI:1467757526
Name:PETRONIS, RYAN WILLIAM
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WILLIAM
Last Name:PETRONIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 EAST BLAND ST
Mailing Address - Street 2:APT 433
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:518-588-6099
Mailing Address - Fax:
Practice Address - Street 1:1142 N BROOME ST
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-9378
Practice Address - Country:US
Practice Address - Phone:704-843-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist