Provider Demographics
NPI:1235956665
Name:PETROSIAN, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PETROSIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7236 S RECOVERY RD
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-8901
Mailing Address - Country:US
Mailing Address - Phone:209-888-6595
Mailing Address - Fax:
Practice Address - Street 1:7236 S RECOVERY RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-8901
Practice Address - Country:US
Practice Address - Phone:209-888-6595
Practice Address - Fax:209-888-6596
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker