Glen Ross Pettenger, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

PA00952 Issued in TX

Practice address

102 West Main Street
Centerville, TX 75833

Phone

(903) 536-2313

Fax

(903) 536-2207

NPI assigned

Mar 19, 2007

Last updated

Jul 8, 2007By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174262400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1801910609",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8148 FM 1511",
            "city": "OAKWOOD",
            "state": "TX",
            "postal_code": "758554067",
            "telephone_number": "903-536-2810"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 WEST MAIN STREET",
            "city": "CENTERVILLE",
            "state": "TX",
            "postal_code": "75833",
            "telephone_number": "903-536-2313",
            "fax_number": "903-536-2207"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTENGER",
        "first_name": "GLEN",
        "middle_name": "ROSS",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-03-19",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "TX",
            "license": "PA00952",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Homeland LP
• Leon County (Leon County Senior Nutrition)
• Leon County Pharmacy Inc (Carols Pharmacy)
• Liberty County Hospital District No. 1 (Cass Valley Healthcare Center)
• Med-Trans Corporation
• RTM Enterprises Inc
• St. Joseph Regional Health Center (St. Joseph Powell Memorial Family Health Center)
• Texas Guardian HCS, LLC
• Candace Arnell West, REGISTERED NURSE

• Medical Physician Assistant in Centerville, TX
• Providers in Centerville, TX by specialty
• Medical Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.