Provider Demographics
NPI:1619108172
Name:PETRONELLA, MELISSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:PETRONELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RXR PLZ FL 13
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:646-846-3283
Practice Address - Street 1:1255 RARITAN RD STE F4B
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066
Practice Address - Country:US
Practice Address - Phone:848-206-0078
Practice Address - Fax:848-206-0078
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00221000363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00221000Medicaid
NJ25MP00221000Medicaid