Provider Demographics
NPI:1124707484
Name:PETROSYAN, ANITA (PA)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:PETROSYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 ORANGE GROVE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1300
Mailing Address - Country:US
Mailing Address - Phone:818-744-6334
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE UNIT 7
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8897
Practice Address - Country:US
Practice Address - Phone:818-744-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant