Provider Demographics
NPI:1790795896
Name:KOSLAP PETRACO, MARY (NP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:KOSLAP PETRACO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 SUNRISE HIGHWAY
Mailing Address - Street 2:MAXINE S POSTAL TRI COMMUNITY HEALTH CENTER
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:631-854-1000
Mailing Address - Fax:631-854-1031
Practice Address - Street 1:1080 SUNRISE HIGHWAY
Practice Address - Street 2:MAXINE S POSTAL TRI COMMUNITY HEALTH CENTER
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-854-1000
Practice Address - Fax:631-854-1031
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380420363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473170Medicaid
NY00473170Medicaid
S84023Medicare UPIN