Provider Demographics
NPI:1619284767
Name:TIARKS, TRISTAN NATHANIEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:NATHANIEL
Last Name:TIARKS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 EDGESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8717
Mailing Address - Country:US
Mailing Address - Phone:479-619-5514
Mailing Address - Fax:
Practice Address - Street 1:306 E 11TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-6156
Practice Address - Country:US
Practice Address - Phone:479-967-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist