Provider Demographics
NPI:1508139825
Name:CODRESCU, TRISTAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:
Last Name:CODRESCU
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3735 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4352
Mailing Address - Country:US
Mailing Address - Phone:971-678-6839
Mailing Address - Fax:
Practice Address - Street 1:3735 SE YAMHILL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4352
Practice Address - Country:US
Practice Address - Phone:971-678-6839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156290171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist