Provider Demographics
NPI:1467409011
Name:PETTIGREW, KAREN W (CNM)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:W
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 CATHEDRAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-343-9224
Mailing Address - Fax:605-342-1359
Practice Address - Street 1:504 E MONROE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1400
Practice Address - Country:US
Practice Address - Phone:605-721-8939
Practice Address - Fax:605-394-5217
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR01556367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6540023Medicaid
R92485Medicare UPIN
7513Medicare ID - Type Unspecified