Provider Demographics
NPI:1669497152
Name:PETTIT, DENISE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MARIE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:MARIE
Other - Last Name:RHOADS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:304-263-9450
Practice Address - Street 1:101 MARCLEY DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-8911
Practice Address - Fax:304-263-9450
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052197363AM0700X
WV01252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9930421OtherMEDICARE GROUP NUMBER
WVWV3241AMedicare PIN
WVWV3241BMedicare PIN