Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 20A13395 | CA |
NPI | 1053552745 |
---|---|
Provider Name | Dr. Jonathan Matthew Pettegrew |
First Address | Modesto, CA 95350-5512 |
Second Address | Modesto, CA 95350-5512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2009 |
Last Update Date | 23/06/2014 |