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General NPI Number Information
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NPI Number | 1801910609
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Entity Type | Individual
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Provider Name | GLEN ROSS PETTENGER PA-C
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Gender | Male
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 102 WEST MAIN STREET
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City | CENTERVILLE
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State | TX
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Zip | 75833
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Country | US
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Telephone | 903-536-2313
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Fax | 903-536-2207
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Provider Business Mailing Address
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Address Line | 8148 FM 1511
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City | OAKWOOD
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State | TX
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Zip | 75855-4067
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Country | US
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Telephone | 903-536-2810
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA00952
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License Number State | TX
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