Provider Demographics
NPI:1891208674
Name:PETTIT, BRADLEY NEAL (CSFA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:NEAL
Last Name:PETTIT
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 FM 172
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-7105
Mailing Address - Country:US
Mailing Address - Phone:940-613-6333
Mailing Address - Fax:
Practice Address - Street 1:579 FM 172
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365-7105
Practice Address - Country:US
Practice Address - Phone:940-613-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170849246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant