Provider Demographics
NPI:1114219466
Name:FUJITA, TRISTAN NADIENE (ATC-R, OTC)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:NADIENE
Last Name:FUJITA
Suffix:
Gender:F
Credentials:ATC-R, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16790 SE DAVIDOFF WAY
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-5807
Mailing Address - Country:US
Mailing Address - Phone:360-204-1035
Mailing Address - Fax:
Practice Address - Street 1:831 NW COUNCIL DR STE 130
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3722
Practice Address - Country:US
Practice Address - Phone:503-489-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR246ZS0410X
ORAT-AT-101394592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer