Provider Demographics
NPI:1972855302
Name:PETRIELLA, NICHOLAS J (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PETRIELLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 NORTH AVE EAST
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016
Mailing Address - Country:US
Mailing Address - Phone:908-967-6124
Mailing Address - Fax:908-967-6126
Practice Address - Street 1:198 NORTH AVE E
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2469
Practice Address - Country:US
Practice Address - Phone:908-967-6124
Practice Address - Fax:908-967-6126
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00151500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical