Provider Demographics
NPI:1407485808
Name:PETTY, MITCHELL RYAN
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RYAN
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 W SAN ANTONIO ST
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2657
Mailing Address - Country:US
Mailing Address - Phone:512-913-8036
Mailing Address - Fax:
Practice Address - Street 1:419 W SAN ANTONIO ST
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-2657
Practice Address - Country:US
Practice Address - Phone:512-913-8036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program