Provider Demographics
NPI:1073217949
Name:WHITE, TRISTAN PHOENIX I
Entity Type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:PHOENIX
Last Name:WHITE
Suffix:I
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 1:397 OLIVER RD
Mailing Address - Street 2:
Mailing Address - City:MINFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45653-8661
Mailing Address - Country:US
Mailing Address - Phone:740-876-2601
Mailing Address - Fax:
Practice Address - Street 1:397 OLIVER RD
Practice Address - Street 2:
Practice Address - City:MINFORD
Practice Address - State:OH
Practice Address - Zip Code:45653-8661
Practice Address - Country:US
Practice Address - Phone:740-876-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health