Provider Demographics
NPI:1508088196
Name:PICO, TRISTAN (MD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:PICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20280 N 59TH AVE
Mailing Address - Street 2:STE 115-617
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:602-795-8700
Mailing Address - Fax:602-795-8701
Practice Address - Street 1:725 S DOBSON RD
Practice Address - Street 2:STE 100
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5680
Practice Address - Country:US
Practice Address - Phone:602-795-8700
Practice Address - Fax:602-795-8701
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0066661207LP2900X
AZ42864207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ514699Medicaid
AZ514699Medicaid