Provider Demographics
NPI:1720069198
Name:PETTINE, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:PETTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4795 LARIMER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534
Mailing Address - Country:US
Mailing Address - Phone:970-669-8881
Mailing Address - Fax:970-669-4200
Practice Address - Street 1:4795 LARIMER PARKWAY
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534
Practice Address - Country:US
Practice Address - Phone:970-669-8881
Practice Address - Fax:970-669-4200
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29524207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01295245Medicaid
COCB7718Medicare PIN
CO01295245Medicaid