Provider Demographics
NPI:1922104397
Name:PETIT, RICHARD G (PA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:G
Last Name:PETIT
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:748 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 185
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3393
Mailing Address - Country:US
Mailing Address - Phone:770-277-8554
Mailing Address - Fax:770-277-1799
Practice Address - Street 1:748 OLD NORCROSS RD
Practice Address - Street 2:SUITE 185
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3393
Practice Address - Country:US
Practice Address - Phone:770-277-8554
Practice Address - Fax:770-277-1799
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-05-28
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Provider Licenses
StateLicense IDTaxonomies
GA001435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA863192094AMedicaid
GA97WCFDKMedicare ID - Type Unspecified
GA863192094AMedicaid