Provider Demographics
NPI:1558092700
Name:PETTIT, HANNAH JO (PA-C)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:JO
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:JO
Other - Last Name:CASTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1909 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2410 SUSANNAH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1748
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:423-282-0035
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5062363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty