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General NPI Number Information
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NPI Number | 1881809861
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Entity Type | Individual
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Provider Name | MICHELLE MARIE PETRIE M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 34800 BOB WILSON DR
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City | SAN DIEGO
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State | CA
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Zip | 92134-3607
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Country | US
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Telephone | 619-218-0034
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 191
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City | ROCKLAND
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State | DE
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Zip | 19732-0191
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Country | US
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Telephone |
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 390200000X
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207LP3000X
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Taxonomy Name | Pediatric Anesthesiology Physician
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License Number | A100930
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License Number State | CA
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