Provider Demographics
NPI:1689934895
Name:ANDERSON, TRISTA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:MICHELLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 E. COUNTY LINE ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0990
Practice Address - Country:US
Practice Address - Phone:317-497-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28168862A363LW0102X
IN71004062A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01316451OtherMEDICARE RR PTAN
IN201082150Medicaid
INP01316451OtherMEDICARE RR PTAN