Provider Demographics
NPI:1689825879
Name:PETTIS, HEATHER M (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:PETTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:MURTAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK BLVD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9274
Mailing Address - Country:US
Mailing Address - Phone:804-765-5529
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249421207P00000X
CAA108901207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine