Provider Demographics
NPI:1568896520
Name:PETOSA, KRISTIN (DPT)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:PETOSA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 MASON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3130
Mailing Address - Country:US
Mailing Address - Phone:732-672-1180
Mailing Address - Fax:
Practice Address - Street 1:72 ROUTE 27
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3986
Practice Address - Country:US
Practice Address - Phone:732-352-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01514600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist