Provider Demographics
NPI:1932122439
Name:PIERCE, TRISTYN AMY (MD)
Entity Type:Individual
Prefix:
First Name:TRISTYN
Middle Name:AMY
Last Name:PIERCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRISTYN
Other - Middle Name:AMY
Other - Last Name:CYRIAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10202 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4377
Mailing Address - Country:US
Mailing Address - Phone:316-729-9100
Mailing Address - Fax:316-729-9185
Practice Address - Street 1:10202 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4377
Practice Address - Country:US
Practice Address - Phone:316-729-9100
Practice Address - Fax:316-729-9185
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32917207R00000X, 208000000X
WAMD00046116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8465775Medicaid
WAUS7603833OtherAETNA
WA0039581OtherL&I
WA8851PIOtherBLUE SHIELD
I58233Medicare UPIN
WA0039581OtherL&I