Provider Demographics
NPI:1902851645
Name:PETTAY, JOHN ALTON (FNP C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALTON
Last Name:PETTAY
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Gender:M
Credentials:FNP C
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Mailing Address - Street 1:1105 PEBBLE BEND DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017
Mailing Address - Country:US
Mailing Address - Phone:770-985-2845
Mailing Address - Fax:770-985-2845
Practice Address - Street 1:2295 HENRY CLOWER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-972-4871
Practice Address - Fax:770-979-3782
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN107083 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKTQMedicare UPIN