Provider Demographics
NPI:1508302761
Name:PETTITT, ERIC (CRNA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PETTITT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12176 83RD LN N
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33412-2288
Mailing Address - Country:US
Mailing Address - Phone:850-292-2431
Mailing Address - Fax:
Practice Address - Street 1:301 LANDINGS DR
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3242
Practice Address - Country:US
Practice Address - Phone:850-292-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9346602367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered