Glen Ross Pettenger, PA-C
Individual provider Active NPI Medical Physician Assistant · Centerville, TX
NPI 1801910609 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1801910609
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- License
- PA00952 (TX)
- Practice address
- 102 West Main Street
Centerville, TX 75833 - Phone
- (903) 536-2313
- Fax
- (903) 536-2207
- NPI assigned
- Mar 19, 2007
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA00952 | TX | Yes |
Addresses
Primary practice location
102 West Main Street
Centerville, TX 75833
Mailing address
8148 FM 1511
Oakwood, TX 75855-4067
Phone (903) 536-2810
Other providers in Centerville, TX
- Homeland LP
- Leon County
- Leon County Pharmacy Inc
- Liberty County Hospital District No. 1
- Med-Trans Corporation
- RTM Enterprises Inc
- St. Joseph Regional Health Center
- Texas Guardian HCS, LLC
- Candace Arnell West
All providers in Centerville, TX · Medical Physician Assistant in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.