Provider Demographics
NPI:1265447619
Name:PETWAY, ZANDRA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:ZANDRA
Middle Name:RENEE
Last Name:PETWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 WALLACE RD STE B307
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4881
Mailing Address - Country:US
Mailing Address - Phone:615-884-0215
Mailing Address - Fax:615-884-0219
Practice Address - Street 1:395 WALLACE RD STE B307
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4881
Practice Address - Country:US
Practice Address - Phone:615-884-0215
Practice Address - Fax:615-884-0219
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27699208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3802977Medicaid
TN3802977Medicaid
TNG28853Medicare UPIN