Provider Demographics
NPI:1336476514
Name:PETTY, TREY COLIN (RT(R))
Entity Type:Individual
Prefix:
First Name:TREY
Middle Name:COLIN
Last Name:PETTY
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 37TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-2615
Mailing Address - Country:US
Mailing Address - Phone:806-778-8017
Mailing Address - Fax:
Practice Address - Street 1:4508 37TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-2615
Practice Address - Country:US
Practice Address - Phone:806-778-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233642471C3402X
WART 000070612471C3402X
CARHF 962472471C3402X
HIR-30582471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography