Provider Demographics
NPI:1710569884
Name:ANDERSON, TRISTAN DANIEL
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:DANIEL
Last Name:ANDERSON
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 1:101 N GREENWOOD AVE STE 131
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-1444
Mailing Address - Country:US
Mailing Address - Phone:918-599-7277
Mailing Address - Fax:
Practice Address - Street 1:101 N GREENWOOD AVE STE 131
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-1444
Practice Address - Country:US
Practice Address - Phone:918-599-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator