Provider Demographics
NPI:1285440487
Name:ANDERSON, TRISTAN (PTA)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423B MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5545
Mailing Address - Country:US
Mailing Address - Phone:769-242-2772
Mailing Address - Fax:769-242-0513
Practice Address - Street 1:423B MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5545
Practice Address - Country:US
Practice Address - Phone:769-242-2772
Practice Address - Fax:769-242-0513
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7598225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant