Provider Demographics
NPI:1316049448
Name:PETRUZZI, ANTHONY MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:PETRUZZI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17406 ROYALTON RD
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-5151
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:440-846-2832
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22937Medicare UPIN
PEPA23371Medicare ID - Type Unspecified