Provider Demographics
NPI:1982884524
Name:PETTIS, MARK E (PTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:PETTIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 STANLEY CT
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-4159
Mailing Address - Country:US
Mailing Address - Phone:219-362-2744
Mailing Address - Fax:
Practice Address - Street 1:203 STANLEY CT
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-4159
Practice Address - Country:US
Practice Address - Phone:219-362-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003247A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker