Provider Demographics
NPI:1730485251
Name:ELLISON, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:ELLISON
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 1:19 ACORN VALLEY TRL
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1935
Mailing Address - Country:US
Mailing Address - Phone:585-755-3823
Mailing Address - Fax:
Practice Address - Street 1:19 ACORN VALLEY TRL
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1935
Practice Address - Country:US
Practice Address - Phone:585-755-3823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10 303992164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10 303992Medicaid