Provider Demographics
NPI:1750899076
Name:CROCKETT, TRISTIAN CORBIN
Entity type:Individual
Prefix:
First Name:TRISTIAN
Middle Name:CORBIN
Last Name:CROCKETT
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 1:4099 DAUGHERTY RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-1993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30461 GARNAND DR
Practice Address - Street 2:
Practice Address - City:EMORY
Practice Address - State:VA
Practice Address - Zip Code:24327
Practice Address - Country:US
Practice Address - Phone:540-580-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program