Healthcare Provider Details

I. General information

NPI: 1194447367
Provider Name (Legal Business Name): PETRISOR TUDOR PMHNP-BC, APRN, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11404 W DODGE RD STE 300
OMAHA NE
68154-2511
US

IV. Provider business mailing address

421 S 243RD ST
WATERLOO NE
68069-4704
US

V. Phone/Fax

Practice location:
  • Phone: 402-898-1113
  • Fax: 402-819-5588
Mailing address:
  • Phone: 402-417-2524
  • Fax: 402-465-8717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number114357
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: