Provider Demographics
NPI:1215040290
Name:PETTER, AMANDA N (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:N
Last Name:PETTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:N
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:204 S IH 35
Mailing Address - Street 2:STE 203
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-4126
Mailing Address - Country:US
Mailing Address - Phone:512-863-7761
Mailing Address - Fax:512-863-0973
Practice Address - Street 1:204 S IH 35
Practice Address - Street 2:STE 203
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-4126
Practice Address - Country:US
Practice Address - Phone:512-863-7761
Practice Address - Fax:512-863-0973
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1134153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7268629OtherAETNA HEALTHCARE
TX2274981OtherFIRST HEALTH
TX676548Medicare ID - Type Unspecified