Healthcare Provider Details

I. General information

NPI: 1821902792
Provider Name (Legal Business Name): MICHAEL ANTHONY PETROCCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 WOLF RD STE 105
ALBANY NY
12205-6008
US

IV. Provider business mailing address

219 DEER RUN DR APT C
HUDSON FALLS NY
12839-2757
US

V. Phone/Fax

Practice location:
  • Phone: 518-437-0152
  • Fax:
Mailing address:
  • Phone: 518-479-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number342928
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: