Healthcare Provider Details

I. General information

NPI: 1376466532
Provider Name (Legal Business Name): GEVORK GEORGE PETROSYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CAMERON PL APT 105
GLENDALE CA
91207-2166
US

IV. Provider business mailing address

400 CAMERON PL APT 105
GLENDALE CA
91207-2166
US

V. Phone/Fax

Practice location:
  • Phone: 818-434-7676
  • Fax:
Mailing address:
  • Phone: 818-434-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: