Provider Demographics
NPI:1508214537
Name:PETRUCCI, ANTHONY J (PT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:PETRUCCI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-2708
Mailing Address - Country:US
Mailing Address - Phone:315-745-9438
Mailing Address - Fax:
Practice Address - Street 1:235 NORTH AVE
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1051
Practice Address - Country:US
Practice Address - Phone:315-536-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021694261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy