Provider Demographics
NPI:1689320178
Name:MAXWELL, TRISTAN (DC)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 NE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3614
Mailing Address - Country:US
Mailing Address - Phone:509-607-9541
Mailing Address - Fax:
Practice Address - Street 1:284 CENTRAL WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6104
Practice Address - Country:US
Practice Address - Phone:425-605-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61259413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty