Provider Demographics
NPI:1033187596
Name:PETTENGILL, THEODORE J (PA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:PETTENGILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:ME
Mailing Address - Zip Code:04776-0000
Mailing Address - Country:US
Mailing Address - Phone:207-365-4335
Mailing Address - Fax:207-365-4336
Practice Address - Street 1:226 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:ME
Practice Address - Zip Code:04776-0000
Practice Address - Country:US
Practice Address - Phone:207-365-4335
Practice Address - Fax:207-365-4336
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA048363A00000X
MEPA48363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME250940099Medicaid
MEAP0428Medicare PIN
MES31610Medicare UPIN
ME250940099Medicaid