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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 |
