Provider Demographics
NPI:1699355693
Name:LOESBERG, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:LOESBERG
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 1:515 N CLARKSON ST APT 301
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-3234
Mailing Address - Country:US
Mailing Address - Phone:808-344-2439
Mailing Address - Fax:
Practice Address - Street 1:333 CITY BLVD W STE 2150
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-5920
Practice Address - Country:US
Practice Address - Phone:888-456-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program