Provider Demographics
NPI:1114161999
Name:RISTER, JOHN WAYNE (IDMT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WAYNE
Last Name:RISTER
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 TRUEMPER ST
Mailing Address - Street 2:BLDG 9225, SUITE 1, ROOM 323
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5568
Mailing Address - Country:US
Mailing Address - Phone:210-671-8317
Mailing Address - Fax:
Practice Address - Street 1:1220 TRUEMPER ST
Practice Address - Street 2:BLDG 9225, SUITE 1, ROOM 323
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5568
Practice Address - Country:US
Practice Address - Phone:210-671-8317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians