Provider Demographics
NPI:1518193184
Name:PETTIT, ETHAN (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N 100 W
Mailing Address - Street 2:STE 106
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2049
Mailing Address - Country:US
Mailing Address - Phone:435-789-9060
Mailing Address - Fax:435-781-3048
Practice Address - Street 1:175 N 100 W
Practice Address - Street 2:STE 106
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2049
Practice Address - Country:US
Practice Address - Phone:435-789-9060
Practice Address - Fax:435-781-3048
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics