Provider Demographics
NPI:1356352579
Name:PETROCHKO, NICHOLAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:PETROCHKO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9777
Mailing Address - Country:US
Mailing Address - Phone:503-652-2880
Mailing Address - Fax:503-571-8984
Practice Address - Street 1:9900 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9777
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:503-571-8984
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD010073208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2000698OtherBLUE CROSS OF TENNESSEE
TN3013285Medicaid
TN4535569OtherAETNA
TN3013287Medicare ID - Type Unspecified
TN4535569OtherAETNA