Provider Demographics
NPI:1093930026
Name:HERBERT, TRISTAN LANE
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:LANE
Last Name:HERBERT
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 1:3123 SW DOLPH CT
Mailing Address - Street 2:#1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219
Mailing Address - Country:US
Mailing Address - Phone:502-223-1117
Mailing Address - Fax:
Practice Address - Street 1:1232 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2906
Practice Address - Country:US
Practice Address - Phone:503-227-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion