Provider Demographics
NPI:1740842525
Name:PETRUS, CARYL (PT)
Entity type:Individual
Prefix:
First Name:CARYL
Middle Name:
Last Name:PETRUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3143 WEST RD
Mailing Address - Street 2:
Mailing Address - City:CONSTABLEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13325-2312
Mailing Address - Country:US
Mailing Address - Phone:315-397-8196
Mailing Address - Fax:
Practice Address - Street 1:159 WEST FIRST STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022654-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist