Provider Demographics
NPI:1588839518
Name:PETROFF, LORI MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MICHELLE
Last Name:PETROFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:MICHELLE
Other - Last Name:FAGERLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2100 POWELL ST STE 900
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2657
Mailing Address - Fax:510-879-9096
Practice Address - Street 1:2100 POWELL ST STE 900
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1844
Practice Address - Country:US
Practice Address - Phone:510-350-2657
Practice Address - Fax:510-879-9096
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3795363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical