Provider Demographics
NPI:1518726603
Name:BOWER, TRISTAN SAGE (LMT)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:SAGE
Last Name:BOWER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ROGERS ST NW APT A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9225
Mailing Address - Country:US
Mailing Address - Phone:360-590-8242
Mailing Address - Fax:
Practice Address - Street 1:435 ROGERS ST NW APT A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9225
Practice Address - Country:US
Practice Address - Phone:360-590-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61399487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist