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General NPI Number Information
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NPI Number | 1366903015
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Entity Type | Individual
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Provider Name | JARON LEE PETTIS
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Gender | Male
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Dates
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Enumeration Date | 03/26/2019
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 1331 STATE ST STE 340
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City | LA PORTE
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State | IN
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Zip | 46350-3112
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Country | US
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Telephone | 219-379-3166
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Fax |
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Provider Business Mailing Address
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Address Line | 1331 STATE ST STE 340
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City | LA PORTE
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State | IN
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Zip | 46350-3112
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 01094579A
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License Number State | IN
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