Provider Demographics
NPI:1811090368
Name:PETTENGILL, JOHN NASON (MSPT, CERT MDT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:NASON
Last Name:PETTENGILL
Suffix:
Gender:M
Credentials:MSPT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 HUNTER WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 W AARON DR
Practice Address - Street 2:SUITE104
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-3074
Practice Address - Country:US
Practice Address - Phone:814-235-9995
Practice Address - Fax:814-235-9616
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005964L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT005964LOtherPHYSICAL THERAPY LICENSE
PA125699SG6Medicare ID - Type UnspecifiedPROVIDER NUMBER