Provider Demographics
NPI:1407008634
Name:DALISAY, TRISTAN BOWLEY (PT)
Entity Type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:BOWLEY
Last Name:DALISAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 OLYMPIC RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8327
Mailing Address - Country:US
Mailing Address - Phone:707-419-1616
Mailing Address - Fax:
Practice Address - Street 1:3175 OLYMPIC RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-8327
Practice Address - Country:US
Practice Address - Phone:707-419-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 19680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist