Healthcare Provider Details

I. General information

NPI: 1831984855
Provider Name (Legal Business Name): AMNUAY GOODDAY PETTWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

75 PLEASANT ST
RUMFORD RI
02916-1311
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7272
  • Fax:
Mailing address:
  • Phone: 414-340-9665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number1108467
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP132374
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: