Basic Information
| Provider Information | |||||||||
| NPI: | 1346204658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 241769 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995241769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077702380 | ||||||||
| FaxNumber: | 9077702341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11551 TANGLEWOOD LAKE CIRCLE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995161304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075627745 | ||||||||
| FaxNumber: | 9075627808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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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 | 225100000X | 67 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT0577 | 05 | AK | MEDICAID |