Individual
MICHAEL J PETRUSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2704 N TENAYA WAY, SUITE 400, LAS VEGAS, NV 89128-0424
(702) 243-8500
Mailing address
PO BOX 15645, SUITE 150, LAS VEGAS, NV 89114-5645
(702) 243-8500
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
6283
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1336112382
SMA MEDICAID
NV
05
—
2019102
—
NV
01
—
V108716
SMA MEDICARE
NV
01
—
V24262
LAB
NV
01
—
VWCGZT
MEDICARE GROUP
NV
Enumeration date
02/09/2006
Last updated
10/28/2014
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