Provider Demographics
NPI:1407161870
Name:PETTY, STEPHANIE JOY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JOY
Last Name:PETTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S CROWLEY RD
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-3698
Mailing Address - Country:US
Mailing Address - Phone:817-297-4455
Mailing Address - Fax:
Practice Address - Street 1:1005 S CROWLEY RD
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-3698
Practice Address - Country:US
Practice Address - Phone:817-297-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant