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NPI Code Detail

MEDICARE: DERRICK DEJUAN PETTIS

MEDICARE: DERRICK DEJUAN PETTIS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1146N00000XBasic Emergency Medical TechnicianB1026491FL

General Provider Information

NPI Number : 1265637847
Entity Type Code : Individual
Provider Name (Legal Business Name) : DERRICK DEJUAN PETTIS
Provider Business Mailing Address
First Line : 11150 4TH ST N APT 4301
Second Line :
City : ST PETERSBURG
State : FL
Zip : 33716-2909
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 600 8TH AVE SE
Second Line :
City : ST PETERSBURG
State : FL
Zip : 33701-5030
Country : US
Telephone Number : 727-502-1602
Fax Number : 727-502-1603
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2007
Last Update Date : 07/08/2007

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Directions to “ DERRICK DEJUAN PETTIS ” Practice Location

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