Provider Demographics
NPI:1417304403
Name:MCKENNA, TRISTAN JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:JOSEPH
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:DO
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-7100
Mailing Address - Fax:515-643-7145
Practice Address - Street 1:2605 SW WHITE BIRCH DR
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7204
Practice Address - Country:US
Practice Address - Phone:515-643-7100
Practice Address - Fax:515-643-7145
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IADO-05812207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM