Basic Information
| Provider Information | |||||||||
| NPI: | 1306270533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTUS | ||||||||
| FirstName: | INDIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7250 PARKWAY DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210761343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | 4439490825 | ||||||||
| Practice Location | |||||||||
| Address1: | 5530 WISCONSIN AVE | ||||||||
| Address2: | SUITE 1660 | ||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208154404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016579876 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2013 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
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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 | 363AS0400X | C0005125 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | C0005125 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.