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 1:2420 W PIERCE ST STE 102
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3517
Practice Address - Country:US
Practice Address - Phone:575-887-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDO2025-0162208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology