Provider Demographics
NPI:1275112104
Name:EVERSON, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:EVERSON
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:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:ROWLESBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26425-0342
Mailing Address - Country:US
Mailing Address - Phone:304-594-8393
Mailing Address - Fax:
Practice Address - Street 1:34 LANTZ RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROWLESBURG
Practice Address - State:WV
Practice Address - Zip Code:26425-9230
Practice Address - Country:US
Practice Address - Phone:304-594-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker