MEDICARE: MRS. CARMEN M PETRUS P.A.

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	363AM0700X	Medical Physician Assistant	PA14772	CA

General Provider Information

NPI Number	:	1467458455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARMEN M PETRUS P.A.

Provider Business Mailing Address
First Line	:	1211 W LA PALMA AVE
Second Line	:	STE 502
City	:	ANAHEIM
State	:	CA
Zip	:	92801-2815
Country	:	US
Telephone Number	:	714-776-7090
Fax Number	:	714-776-5632

Provider Business Practice Location Address
First Line	:	1211 W LA PALMA AVE
Second Line	:	STE 502
City	:	ANAHEIM
State	:	CA
Zip	:	92801-2815
Country	:	US
Telephone Number	:	714-776-7090
Fax Number	:	714-776-5632

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	04/21/2011

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