Healthcare Provider Details

I. General information

NPI: 1316460827
Provider Name (Legal Business Name): SARA PETSKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 VILLAGE SQ
GRETNA NE
68028-7914
US

IV. Provider business mailing address

814 VILLAGE SQ
GRETNA NE
68028-7914
US

V. Phone/Fax

Practice location:
  • Phone: 402-332-0220
  • Fax: 402-332-0440
Mailing address:
  • Phone: 402-332-0220
  • Fax: 402-332-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2063
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1486
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: