Healthcare Provider Details

I. General information

NPI: 1831969542
Provider Name (Legal Business Name): EASTON PETITT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

4215 FUDGES CREEK RD
BARBOURSVILLE WV
25504-8010
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5000
  • Fax:
Mailing address:
  • Phone: 304-417-1596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010405RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: