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General NPI Number Information
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NPI Number | 1336112382
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Entity Type | Individual
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Provider Name | MICHAEL J PETRUSO M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/09/2006
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 2704 N TENAYA WAY SUITE 400
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City | LAS VEGAS
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State | NV
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Zip | 89128-0424
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Country | US
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Telephone | 702-243-8500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 15645 SUITE 150
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City | LAS VEGAS
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State | NV
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Zip | 89114-5645
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Country | US
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Telephone | 702-243-8500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 6283
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License Number State | NV
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