Provider Demographics
NPI:1689457319
Name:BLAIR, TRISTAN RYAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:RYAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15190 SEGOVIA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1219
Mailing Address - Country:US
Mailing Address - Phone:661-525-6165
Mailing Address - Fax:
Practice Address - Street 1:15190 SEGOVIA CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-1219
Practice Address - Country:US
Practice Address - Phone:661-525-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF8351466OtherDRIVER LICENSE