Provider Demographics
NPI:1568504827
Name:PETTIS, RENEE DELISE (PA-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:DELISE
Last Name:PETTIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8325 BROADWAY ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5773
Mailing Address - Country:US
Mailing Address - Phone:281-764-8527
Mailing Address - Fax:
Practice Address - Street 1:412 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-1840
Practice Address - Country:US
Practice Address - Phone:713-926-6229
Practice Address - Fax:713-926-9105
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC247363AM0700X
LAPA.200446363AM0700X
DCPA247363AM0700X
TXPA07388363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical