Individual
MR. GREGORY PETTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3350 LA JOLLA VILLAGE DR, SAN DIEGO, CA 92161-0002
(858) 552-8585
Mailing address
3350 LA JOLLA VILLAGE DR, SAN DIEGO, CA 92161-0002
(858) 552-8585
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-03251
NC
363A00000X
Physician Assistant
005159
GA
363A00000X
Physician Assistant
Primary
20371
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
58-2155150
COMPANY TAX ID
GA
Enumeration date
09/21/2007
Last updated
02/23/2015
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