Provider Demographics
NPI:1104048842
Name:TISTAN, CAROL J (ACUPUNCTURIST)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:J
Last Name:TISTAN
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-3638
Mailing Address - Country:US
Mailing Address - Phone:908-213-1060
Mailing Address - Fax:
Practice Address - Street 1:1073 PEARL ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-3638
Practice Address - Country:US
Practice Address - Phone:908-213-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00028800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist