Provider Demographics
NPI:1336206952
Name:PETRUNGARO, ERCOLE JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:ERCOLE
Middle Name:JOHN
Last Name:PETRUNGARO
Suffix:
Gender:M
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 1:121 GARY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6807
Mailing Address - Country:US
Mailing Address - Phone:718-227-2515
Mailing Address - Fax:
Practice Address - Street 1:100 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4227
Practice Address - Country:US
Practice Address - Phone:718-780-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00256900363A00000X
NY010815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant