Provider Demographics
NPI:1659038750
Name:CRAY, TRISTAN OLIVER (PTA)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:OLIVER
Last Name:CRAY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PINE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3886
Mailing Address - Country:US
Mailing Address - Phone:207-313-9916
Mailing Address - Fax:
Practice Address - Street 1:67 PINE POINT RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8813
Practice Address - Country:US
Practice Address - Phone:207-883-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA6103225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant