Individual
MR. MARK E PETTIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
203 STANLEY CT, LA PORTE, IN 46350-4159
(219) 362-2744
Mailing address
203 STANLEY CT, LA PORTE, IN 46350-4159
(219) 362-2744
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
06003247A
IN
Other
Enumeration date
11/12/2007
Last updated
08/25/2008
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