Provider Demographics
NPI:1306184874
Name:PENDERGRAST, TRISTA LEE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:LEE
Last Name:PENDERGRAST
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:LEE
Other - Last Name:PULLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-2501
Practice Address - Fax:360-428-2596
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60330625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily