Basic Information
| Provider Information | |||||||||
| NPI: | 1558557785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 005159 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-03251 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 20371 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 58-2155150 | 01 | GA | COMPANY TAX ID | OTHER |