Provider Demographics
NPI:1942632245
Name:PACK, TRISTEN AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:TRISTEN
Middle Name:AMBER
Last Name:PACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRISTEN
Other - Middle Name:AMBER
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:388 BEN BOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-5386
Mailing Address - Country:US
Mailing Address - Phone:276-988-8740
Mailing Address - Fax:276-988-5941
Practice Address - Street 1:388 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-5386
Practice Address - Country:US
Practice Address - Phone:276-988-8740
Practice Address - Fax:276-988-5941
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA54-0506332363A00000X
VA0110004364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant