MEDICARE: KRISTINA J PETTY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	686	NV

General Provider Information

NPI Number	:	1538479365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA J PETTY O.D.

Provider Business Mailing Address
First Line	:	561 KEYSTONE AVE # 143
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89503-4304
Country	:	US
Telephone Number	:	775-338-0883
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 US HIGHWAY 95A S
Second Line	:	UNIT A
City	:	FERNLEY
State	:	NV
Zip	:	89408-9261
Country	:	US
Telephone Number	:	775-575-5700
Fax Number	:	775-575-5702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2010
Last Update Date	:	03/20/2023

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