Provider Demographics
NPI:1083643548
Name:PETTIT, MARY E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64664
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4664
Mailing Address - Country:US
Mailing Address - Phone:410-550-0453
Mailing Address - Fax:
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-581-8767
Practice Address - Fax:727-581-2739
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7048BMedicare PIN
P34772Medicare UPIN