Provider Demographics
NPI:1427783315
Name:PETTWAY, KRISTOFER KEDAR
Entity type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:KEDAR
Last Name:PETTWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S NORMADE AVE APT 732
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3396
Mailing Address - Country:US
Mailing Address - Phone:516-919-0615
Mailing Address - Fax:
Practice Address - Street 1:411 S NORMADE AVE APT 732
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3396
Practice Address - Country:US
Practice Address - Phone:516-919-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-23
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19393832405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional