Provider Demographics
NPI:1861587560
Name:PETTIT, JEROME L (PA-C)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:PETTIT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602229
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2229
Mailing Address - Country:US
Mailing Address - Phone:828-894-3718
Mailing Address - Fax:828-894-3806
Practice Address - Street 1:155 W MILLS ST STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-9462
Practice Address - Country:US
Practice Address - Phone:833-365-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC970030947OtherMEDICARE RR PROVIDER NUMB
NC1861587560Medicaid
SC0816PAMedicaid
NC8102639Medicaid
NC27671OtherMEDCOST PROVIDER NUMBER
NCP82578Medicare UPIN
NC2757681EMedicare PIN
NC8102639Medicaid
NCNC3852AMedicare PIN
NC970030947OtherMEDICARE RR PROVIDER NUMB
NC2757681DMedicare PIN
NC2757681BMedicare PIN