Basic Information
| Provider Information | |||||||||
| NPI: | 1174734818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTERWAY | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLYARD | ||||||||
| OtherFirstName: | GRETCHEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692820996 | ||||||||
| Practice Location | |||||||||
| Address1: | 9220 ELLERBE RD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711066739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186815282 | ||||||||
| FaxNumber: | 3186815284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.202577 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1079219 | 05 | LA | MEDICAID |