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Jerry Miller Petty

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NPI Number Detailed Information

Provider Information:

Name: Jerry Miller Petty
Gender: M
Provider License Number If Given: 11925

NPI Information:

NPI: 1124027628
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 7/18/2005

Last Update Date: 10/23/2012

Provider Business Mailing Address:

Address: 225 BALDWIN AVE
Charlotte, NC 28204
Phone Number: 7043761605
Fax Number: 7043358448

Provider Business Practice Location Address:

Address: 225 BALDWIN AVE
Charlotte, NC 28204
Phone Number: 7043761605
Fax Number: 7043358448

Provider Taxonomy:

Primary: 207T00000X
Secondary (if any):
State: NC

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