Provider Demographics
NPI:1336754787
Name:FULLER-NIXON, TRISTAN NOHL
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:NOHL
Last Name:FULLER-NIXON
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 1:2311 STREAMBED CT APT 2007
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-6015
Mailing Address - Country:US
Mailing Address - Phone:214-434-3263
Mailing Address - Fax:
Practice Address - Street 1:2311 STREAMBED CT APT 2007
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-6015
Practice Address - Country:US
Practice Address - Phone:214-434-3263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15416902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer