Provider Demographics
NPI:1053044669
Name:PETERSON, TRISTIN
Entity Type:Individual
Prefix:
First Name:TRISTIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 MABEN AVE
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:IA
Mailing Address - Zip Code:50438-1732
Mailing Address - Country:US
Mailing Address - Phone:641-425-4651
Mailing Address - Fax:
Practice Address - Street 1:434 WALLACE RD
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011-0001
Practice Address - Country:US
Practice Address - Phone:515-294-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer