Provider Demographics
NPI:1376962712
Name:PETTUS, MICHAEL LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOGAN
Last Name:PETTUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9735 KINCEY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-9120
Mailing Address - Country:US
Mailing Address - Phone:704-500-2332
Mailing Address - Fax:704-274-2048
Practice Address - Street 1:9735 KINCEY AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-9120
Practice Address - Country:US
Practice Address - Phone:704-500-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202000739207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology