Individual
MR. GLEN ROSS PETTENGER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
102 WEST MAIN STREET, CENTERVILLE, TX 75833
(903) 536-2313
(903) 536-2207
Mailing address
8148 FM 1511, OAKWOOD, TX 75855-4067
(903) 536-2810
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA00952
TX
Other
Enumeration date
03/19/2007
Last updated
07/08/2007
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