Provider Demographics
NPI:1912428202
Name:PETITTI, BRAD (PA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:PETITTI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 W RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 POMEROY AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7482
Practice Address - Country:US
Practice Address - Phone:203-694-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant