Healthcare Provider Details

I. General information

NPI: 1134641608
Provider Name (Legal Business Name): ADRIAN PETTAWAY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 W RIO SALADO PKWY
MESA AZ
85201-3603
US

IV. Provider business mailing address

4600 S FOUR MILE RUN DR APT 634
ARLINGTON VA
22204-3514
US

V. Phone/Fax

Practice location:
  • Phone: 301-275-1176
  • Fax:
Mailing address:
  • Phone: 301-275-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: