Provider Demographics
NPI:1932351822
Name:PETRARCA, MICHAEL RAYMOND (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:PETRARCA
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12570 VENICIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8145
Mailing Address - Country:US
Mailing Address - Phone:603-978-1261
Mailing Address - Fax:
Practice Address - Street 1:12570 VENICIA DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8145
Practice Address - Country:US
Practice Address - Phone:603-978-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer