Provider Demographics
NPI:1083441703
Name:TEETS, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:TEETS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2633
Mailing Address - Country:US
Mailing Address - Phone:585-485-3024
Mailing Address - Fax:
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751854-01208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics