Healthcare Provider Details

I. General information

NPI: 1568280345
Provider Name (Legal Business Name): JOSEPH PETROLLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 CLINGAN RD
POLAND OH
44514-2196
US

IV. Provider business mailing address

6615 CLINGAN RD
POLAND OH
44514-2196
US

V. Phone/Fax

Practice location:
  • Phone: 330-757-7888
  • Fax:
Mailing address:
  • Phone: 330-757-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009061RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: