Provider Demographics
NPI:1336206952
Name:PETRUNGARO, ERCOLE JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:ERCOLE
Middle Name:JOHN
Last Name:PETRUNGARO
Suffix:
Gender:
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 1:10 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1225
Mailing Address - Country:US
Mailing Address - Phone:917-921-7226
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-2661
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00256900363A00000X
NY010815363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical