MEDICARE: MITCHELL RYAN PETTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	DO2025-0162	NM

General Provider Information

NPI Number	:	1407485808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL RYAN PETTY

Provider Business Mailing Address
First Line	:	419 W SAN ANTONIO ST
Second Line	:
City	:	LOCKHART
State	:	TX
Zip	:	78644-2657
Country	:	US
Telephone Number	:	512-913-8036
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 W PIERCE ST STE 102
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220-3517
Country	:	US
Telephone Number	:	575-887-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	10/09/2025

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Directions to “ MITCHELL RYAN PETTY ” Practice Location

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