Provider Demographics
NPI:1659421543
Name:PETTIS, SHAWN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:JAMES
Last Name:PETTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9911 WESTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9015 ARBOR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2056
Practice Address - Country:US
Practice Address - Phone:402-384-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19105207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01167OtherBCBSN
NE2001107OtherSHARE ADV-BERGAN SURG
IA4909390Medicaid
NE10025039400Medicaid
NE6332OtherMIDLANDS CHOICE
IA94522OtherBCBSIA
NE10024988700Medicaid
NE10024988600Medicaid
NE10024997200Medicaid
NE10024997400Medicaid
NE2001106OtherSHARE ADV - CLARKSON W
NE2001164OtherSHARE ADV - ARBOR ST.
NE10024997400Medicaid
NE10024988700Medicaid
IA4909390Medicaid
NE6332OtherMIDLANDS CHOICE