Provider Demographics
NPI:1215162508
Name:CLARY, TRISTAN LANCE
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:LANCE
Last Name:CLARY
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 1:5918 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1970
Mailing Address - Country:US
Mailing Address - Phone:501-663-2199
Mailing Address - Fax:501-663-2235
Practice Address - Street 1:5918 LEE AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1509
Practice Address - Country:US
Practice Address - Phone:501-663-2199
Practice Address - Fax:501-663-2235
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator