Provider Demographics
NPI:1134641608
Name:PETTAWAY, ADRIAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:ADRIAN
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 S FOUR MILE RUN DR APT 634
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-3514
Mailing Address - Country:US
Mailing Address - Phone:301-275-1176
Mailing Address - Fax:
Practice Address - Street 1:2510 W RIO SALADO PKWY
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3603
Practice Address - Country:US
Practice Address - Phone:301-275-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-16
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist