Provider Demographics
NPI:1790986875
Name:PETITTE, ANITA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:
Last Name:PETITTE
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-757-1767
Practice Address - Fax:304-757-1716
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00844363A00000X
WV315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1065295OtherWV DWC
WV001796236OtherBLUE CROSS BLUE SHIELD
WV001796236OtherBLUE CROSS BLUE SHIELD
WV18107Medicare PIN
WV18108Medicare PIN