Provider Demographics
NPI:1386214807
Name:PETTIS, SHANE TYLER
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:TYLER
Last Name:PETTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 SWEET HOME RD STE 3-5
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2795
Mailing Address - Country:US
Mailing Address - Phone:716-589-1411
Mailing Address - Fax:716-276-3051
Practice Address - Street 1:1412 SWEET HOME RD STE 3-5
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2795
Practice Address - Country:US
Practice Address - Phone:716-589-1411
Practice Address - Fax:716-276-3051
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist