Provider Demographics
NPI:1700355237
Name:PETTY, WILLIAM CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHRISTOPHER
Last Name:PETTY
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 1:4301 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4472
Mailing Address - Country:US
Mailing Address - Phone:580-558-2635
Mailing Address - Fax:580-558-2314
Practice Address - Street 1:4301 WILSON ST
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4472
Practice Address - Country:US
Practice Address - Phone:580-558-2635
Practice Address - Fax:580-558-2314
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
OK5058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
1158126OtherNCCPA IDENTIFICATION NUMBER