Provider Demographics
NPI:1609115534
Name:PETTIT, MATTHEW J (APRN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:PETTIT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 S MACDILL AVE STE 129-300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-8171
Mailing Address - Country:US
Mailing Address - Phone:813-441-6803
Mailing Address - Fax:813-524-6352
Practice Address - Street 1:3225 S MACDILL AVE STE 129-300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-8171
Practice Address - Country:US
Practice Address - Phone:813-441-6803
Practice Address - Fax:813-524-6352
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9262459363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01970837OtherRAILROAD MEDICARE
FL102049900Medicaid
FLY0H23OtherBCBS
FL008757400Medicaid
FLAPRN9262459OtherFL LICENSE
FLAPRN9262459OtherFL LICENSE