MEDICARE: SUSAN V PETTIS PT

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
1	225100000X	Physical Therapist	67	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346204658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN V PETTIS PT

Provider Business Mailing Address
First Line	:	PO BOX 241769
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99524-1769
Country	:	US
Telephone Number	:	907-770-2380
Fax Number	:	907-770-2341

Provider Business Practice Location Address
First Line	:	11551 TANGLEWOOD LAKE CIRCLE
Second Line	:	SUITE 2
City	:	ANCHORAGE
State	:	AK
Zip	:	99516-1304
Country	:	US
Telephone Number	:	907-562-7745
Fax Number	:	907-562-7808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	09/02/2010

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Directions to “ SUSAN V PETTIS PT” Practice Location

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