Basic Information
| Provider Information | |||||||||
| NPI: | 1144859729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRI | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 NORTH MEADOWS DRIVE | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146634550 | ||||||||
| FaxNumber: | 6146634555 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 NAVAL NUCLEAR POWER TRAINING COMMAND CIR | ||||||||
| Address2: | |||||||||
| City: | GOOSE CREEK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437946819 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2020 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 83718 | SC | N | Other Service Providers | Military Health Care Provider | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | 83718 | SC | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.