Basic Information
| Provider Information | |||||||||
| NPI: | 1558092700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASTOR | ||||||||
| OtherFirstName: | HANNAH | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1909 JAMESTOWN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047640 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2410 SUSANNAH ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829011 | ||||||||
| FaxNumber: | 4232820035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5062 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 5062 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.