Basic Information
| Provider Information | |||||||||
| NPI: | 1922002658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 FRANCE AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528060011 | ||||||||
| FaxNumber: | 9528069741 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FRANCE AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528060011 | ||||||||
| FaxNumber: | 9528069741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 39185 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 288522100 | 05 | MN | MEDICAID |