Provider Demographics
NPI:1508302068
Name:PETTY, DAVID A I (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:PETTY
Suffix:I
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 N AMIDON AVE # S208
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-2126
Mailing Address - Country:US
Mailing Address - Phone:316-832-1116
Mailing Address - Fax:316-832-1138
Practice Address - Street 1:2100 N AMIDON AVE # S208
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2126
Practice Address - Country:US
Practice Address - Phone:316-832-1116
Practice Address - Fax:316-832-1138
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02387225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant