Provider Demographics
NPI:1376506881
Name:PETTWAY, PATTY K (DO)
Entity type:Individual
Prefix:DR
First Name:PATTY
Middle Name:K
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:DO
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 639
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0639
Mailing Address - Country:US
Mailing Address - Phone:479-495-2241
Mailing Address - Fax:479-495-6299
Practice Address - Street 1:310 WEST BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:AR
Practice Address - Zip Code:72842-0099
Practice Address - Country:US
Practice Address - Phone:479-476-2827
Practice Address - Fax:479-476-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8252207Q00000X
KS05-35547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121717003Medicaid
ARF26603Medicare UPIN
AR55686Medicare ID - Type UnspecifiedMEDICARE