Provider Demographics
NPI:1437799954
Name:PETTIGREW, KEITH ALEX III (PA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALEX
Last Name:PETTIGREW
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2710
Mailing Address - Country:US
Mailing Address - Phone:843-673-0122
Mailing Address - Fax:
Practice Address - Street 1:1204 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2710
Practice Address - Country:US
Practice Address - Phone:843-673-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4093PAMedicaid