Provider Demographics
NPI:1447015326
Name:PETROVICH, ADAM HARRISON
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:HARRISON
Last Name:PETROVICH
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 1:3576 CASCADE CT
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6501
Mailing Address - Country:US
Mailing Address - Phone:630-885-0906
Mailing Address - Fax:
Practice Address - Street 1:3576 CASCADE CT
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-6501
Practice Address - Country:US
Practice Address - Phone:630-885-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAG11230017363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology