Healthcare Provider Details

I. General information

NPI: 1801453030
Provider Name (Legal Business Name): PRESTON LEE PETERSON AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2385 E PRATER WAY STE 302
SPARKS NV
89434-9638
US

IV. Provider business mailing address

1155 MILL ST # MCM14
RENO NV
89502-1576
US

V. Phone/Fax

Practice location:
  • Phone: 775-356-4514
  • Fax: 775-356-4991
Mailing address:
  • Phone: 775-982-5262
  • Fax: 775-982-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number822824
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number822824
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: