Provider Demographics
NPI:1356923361
Name:PENNELLA, TRISTAN (DO)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:PENNELLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 WATER ST
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-3158
Mailing Address - Country:US
Mailing Address - Phone:952-906-7855
Mailing Address - Fax:
Practice Address - Street 1:675 WATER ST
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-3158
Practice Address - Country:US
Practice Address - Phone:952-906-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty