Provider Demographics
NPI:1801910609
Name:PETTENGER, GLEN ROSS (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ROSS
Last Name:PETTENGER
Suffix:
Gender:M
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 1:8148 FM 1511
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:75855-4067
Mailing Address - Country:US
Mailing Address - Phone:903-536-2810
Mailing Address - Fax:
Practice Address - Street 1:102 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TX
Practice Address - Zip Code:75833
Practice Address - Country:US
Practice Address - Phone:903-536-2313
Practice Address - Fax:903-536-2207
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00952363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical