Provider Demographics
NPI:1497302962
Name:CHEESMAN, TRISTAN VIZCONDE
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:VIZCONDE
Last Name:CHEESMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 VALLEY VIEW CT
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-6628
Mailing Address - Country:US
Mailing Address - Phone:408-228-7061
Mailing Address - Fax:
Practice Address - Street 1:3210 VALLEY VIEW CT
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-6628
Practice Address - Country:US
Practice Address - Phone:408-228-7061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
NVPA2176363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical