Provider Demographics
NPI:1437146214
Name:CROOK, TRYSTAN J (DO)
Entity Type:Individual
Prefix:
First Name:TRYSTAN
Middle Name:J
Last Name:CROOK
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 741331
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1331
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-469-5267
Practice Address - Street 1:11725 W 112TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2761
Practice Address - Country:US
Practice Address - Phone:913-469-5579
Practice Address - Fax:913-469-0824
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017424207Q00000X
KS0532425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H86D905Medicare ID - Type Unspecified
I33614Medicare UPIN