Provider Demographics
NPI:1366656118
Name:PETTYJOHN, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:PETTYJOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3064 COVINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-7207
Mailing Address - Country:US
Mailing Address - Phone:605-787-2719
Mailing Address - Fax:605-718-4452
Practice Address - Street 1:3064 COVINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-7207
Practice Address - Country:US
Practice Address - Phone:605-787-2719
Practice Address - Fax:605-718-4452
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1366656118Medicare NSC
S105012Medicare UPIN