Healthcare Provider Details

I. General information

NPI: 1548828809
Provider Name (Legal Business Name): KRISTEN PETTI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2019
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26600 CACTUS AVE
MORENO VALLEY CA
92555-3901
US

IV. Provider business mailing address

6715 GOLDY ST
CORONA CA
92880-9281
US

V. Phone/Fax

Practice location:
  • Phone: 951-988-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: