Healthcare Provider Details

I. General information

NPI: 1629743083
Provider Name (Legal Business Name): COLTON RYAN PETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ALCOA HWY # U-107
KNOXVILLE TN
37920-1511
US

IV. Provider business mailing address

910 MADISON AVE STE 1002
MEMPHIS TN
38103-3487
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-5529
  • Fax:
Mailing address:
  • Phone: 901-448-5529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number68958
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: