Provider Demographics
NPI:1548534506
Name:PETTY, TIMOTHY MARC (LIC PHLEBOTOMIST)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARC
Last Name:PETTY
Suffix:
Gender:M
Credentials:LIC PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 S MASON RD
Mailing Address - Street 2:1027
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-5924
Mailing Address - Country:US
Mailing Address - Phone:832-794-7175
Mailing Address - Fax:
Practice Address - Street 1:2002 S MASON RD
Practice Address - Street 2:1027
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-5924
Practice Address - Country:US
Practice Address - Phone:832-794-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200310R11246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy