Provider Demographics
NPI:1568280345
Name:PETROLLA, JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PETROLLA
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 1:6615 CLINGAN RD
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2196
Mailing Address - Country:US
Mailing Address - Phone:330-757-7888
Mailing Address - Fax:
Practice Address - Street 1:6615 CLINGAN RD
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-2196
Practice Address - Country:US
Practice Address - Phone:330-757-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009061RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant