MEDICARE: DIANE PETROVICH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA000042L	PA

General Provider Information

NPI Number	:	1386723534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE PETROVICH PA-C

Provider Business Mailing Address
First Line	:	1084 ROUTE 315
Second Line	:
City	:	WILKES-BARRE
State	:	PA
Zip	:	18702-7012
Country	:	US
Telephone Number	:	570-825-8741
Fax Number	:	570-825-8990

Provider Business Practice Location Address
First Line	:	75 PINEAPPLE STREET
Second Line	:	BLACK CREEK HEALTH CENTER
City	:	NUREMBERG
State	:	PA
Zip	:	18241-0670
Country	:	US
Telephone Number	:	570-384-3201
Fax Number	:	570-384-3454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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