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General NPI Number Information
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NPI Number | 1659256774
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Entity Type | Individual
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Provider Name | NICOLE PETROSKY PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/07/2025
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Last Update Date | 08/07/2025
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Provider Practice Location Address
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Address Line | 1716 REDWOOD HWY # A025
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City | CORTE MADERA
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State | CA
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Zip | 94925-1249
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Country | US
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Telephone | 415-532-3637
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Fax |
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Provider Business Mailing Address
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Address Line | 4 CANTERBURY CT
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City | PETALUMA
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State | CA
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Zip | 94954-4675
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Country | US
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Telephone | 856-776-9360
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 54320
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License Number State | CA
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