Provider Demographics
NPI:1043747553
Name:PAMETICKY, ROWDY (IDC)
Entity Type:Individual
Prefix:
First Name:ROWDY
Middle Name:
Last Name:PAMETICKY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 LOWER GAINSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STENNIS CTR
Mailing Address - State:MS
Mailing Address - Zip Code:39529-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:952 PONI PL
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-4135
Practice Address - Country:US
Practice Address - Phone:228-813-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman