Provider Demographics
NPI:1942404827
Name:PETTY, EMILY JONES (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JONES
Last Name:PETTY
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 1:3020 CHILDRENS WAY # MC5062
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-6789
Mailing Address - Fax:
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102855Medicaid
NC0397730007Medicare NSC
NCNC6273AMedicare PIN