Provider Demographics
NPI:1669463055
Name:PETITT, WILLIAM KIMBALL (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KIMBALL
Last Name:PETITT
Suffix:
Gender:M
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:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1244
Mailing Address - Country:US
Mailing Address - Phone:888-269-7001
Mailing Address - Fax:303-764-6640
Practice Address - Street 1:799 E HAMPDEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2766
Practice Address - Country:US
Practice Address - Phone:303-789-2663
Practice Address - Fax:303-788-4871
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001599363AS0400X, 363AM0700X
CO1599363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000177466Medicaid
COS91595Medicare UPIN