Provider Demographics
NPI:1902331598
Name:PETTY, RYAN (DNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:6379 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8706
Practice Address - Country:US
Practice Address - Phone:810-735-7847
Practice Address - Fax:810-735-7159
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902331598Medicaid