Provider Demographics
NPI:1457870727
Name:PETRO, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETRO
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 1:4461 VALETA ST APT D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1258
Mailing Address - Country:US
Mailing Address - Phone:517-990-4677
Mailing Address - Fax:
Practice Address - Street 1:207 W LEGION RD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant