Healthcare Provider Details

I. General information

NPI: 1033187596
Provider Name (Legal Business Name): THEODORE J PETTENGILL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 MAIN STREET
SHERMAN ME
04776-0000
US

IV. Provider business mailing address

226 MAIN STREET
SHERMAN ME
04776-0000
US

V. Phone/Fax

Practice location:
  • Phone: 207-365-4335
  • Fax: 207-365-4336
Mailing address:
  • Phone: 207-365-4335
  • Fax: 207-365-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA048
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA48
License Number StateME

VII. Legacy identifiers

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

# 1
Identifier250940099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: