Provider Demographics
NPI:1639280332
Name:PETRACCIONE, LISA F (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:F
Last Name:PETRACCIONE
Suffix:
Gender:F
Credentials:RPA-C
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Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:3732 CARMAN RD
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-5422
Practice Address - Country:US
Practice Address - Phone:518-356-4132
Practice Address - Fax:518-355-3996
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-01-26
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Provider Licenses
StateLicense IDTaxonomies
NY004441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000498833001OtherBSNENY
NY070507000057OtherFIDELIS
NY02215098Medicaid
NY356367OtherMVP HEALTHCARE
NYS84864Medicare UPIN
NY356367OtherMVP HEALTHCARE