Provider Demographics
NPI:1083107072
Name:EDMISTON, TORI ANNE (MD)
Entity Type:Individual
Prefix:
First Name:TORI
Middle Name:ANNE
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4723
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:775-786-1887
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-786-3040
Practice Address - Fax:775-788-5216
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV22857207Q00000X, 207QS0010X, 207QS0010X
IL036.156295207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15662269OtherCAQH
NV250021271Medicaid