Provider Demographics
NPI:1457468225
Name:PROETT, TRISTAN (MSPT)
Entity Type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:
Last Name:PROETT
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 11TH ST SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9168
Mailing Address - Country:US
Mailing Address - Phone:541-347-4314
Mailing Address - Fax:541-347-8006
Practice Address - Street 1:913 11TH ST SE
Practice Address - Street 2:SUITE 1
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-4314
Practice Address - Fax:541-347-8006
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269048Medicaid