Provider Demographics
NPI:1285632349
Name:PETRIDIS, DEBORAH L (ANP-C)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:L
Last Name:PETRIDIS
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:2 PALISADES DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1438
Practice Address - Country:US
Practice Address - Phone:518-458-2000
Practice Address - Fax:518-458-1524
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430134363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA2972Medicare ID - Type Unspecified
NYP32435Medicare UPIN