Provider Demographics
NPI:1598945255
Name:PEREZ, TRISTAN ANTONIO BURAGA (RPT)
Entity Type:Individual
Prefix:
First Name:TRISTAN ANTONIO
Middle Name:BURAGA
Last Name:PEREZ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2338
Mailing Address - Country:US
Mailing Address - Phone:626-898-2741
Mailing Address - Fax:
Practice Address - Street 1:2220 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-2338
Practice Address - Country:US
Practice Address - Phone:626-898-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist