Provider Demographics
NPI:1083093025
Name:PETTY, MATTHEW (DVM)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30016 OLD LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:WANSHIP
Mailing Address - State:UT
Mailing Address - Zip Code:84017-9607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30016 OLD LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:WANSHIP
Practice Address - State:UT
Practice Address - Zip Code:84017-9607
Practice Address - Country:US
Practice Address - Phone:812-219-2127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9116831-2802174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian