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General NPI Number Information
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NPI Number | 1972855302
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Entity Type | Individual
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Provider Name | NICHOLAS J PETRIELLA PA
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Gender | Male
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Dates
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Enumeration Date | 10/09/2012
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 198 NORTH AVE E
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City | CRANFORD
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State | NJ
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Zip | 07016-2469
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Country | US
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Telephone | 908-967-6124
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Fax | 908-967-6126
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Provider Business Mailing Address
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Address Line | 198 NORTH AVE EAST
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City | CRANFORD
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State | NJ
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Zip | 07016
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Country | US
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Telephone | 908-967-6124
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Fax | 908-967-6126
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 25MP00151500
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License Number State | NJ
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