Healthcare Provider Details

I. General information

NPI: 1003313487
Provider Name (Legal Business Name): DEBORAH IVANE VYDRA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH IVANE WIRAWAN DO

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 RENO CORPORATE DR
RENO NV
89511-2381
US

IV. Provider business mailing address

5301 RENO CORPORATE DR
RENO NV
89511-2381
US

V. Phone/Fax

Practice location:
  • Phone: 775-329-5555
  • Fax:
Mailing address:
  • Phone: 775-329-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO3286
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: