Provider Demographics
NPI:1649598426
Name:TRI-STATE MEDICAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL SPECIALISTS LLC
Other - Org Name:TRISTATE PAIN INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KNAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TABORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-788-3333
Mailing Address - Street 1:1510 E WAGON WHEEL LN STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6698
Mailing Address - Country:US
Mailing Address - Phone:928-788-3333
Mailing Address - Fax:928-788-3555
Practice Address - Street 1:1510 E WAGON WHEEL LN STE 110
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6698
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LP2900X, 2081P2900X, 208VP0000X, 208VP0014X
AZ20605207T00000X, 208VP0000X
NY5573207T00000X
NV5573208VP0000X
AZAP8599363L00000X, 363LF0000X, 363LP2300X
AZAP3760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527366Medicaid
AZDQ4807OtherMEDICARE RAILROAD GROUP PIN
CACA122120Medicare PIN
AZZ137933Medicare PIN
NVB27285Medicare UPIN
NVFL398AMedicare PIN
AZ6525570001Medicare NSC