Provider Demographics
NPI:1366993818
Name:TRI-STATE VASCULAR GROUP, PLLC
Entity type:Organization
Organization Name:TRI-STATE VASCULAR GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANTZY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-590-0155
Mailing Address - Street 1:PO BOX 9893
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-9893
Mailing Address - Country:US
Mailing Address - Phone:928-788-4944
Mailing Address - Fax:928-788-4949
Practice Address - Street 1:1401 BAILEY AVE BLDG A
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3103
Practice Address - Country:US
Practice Address - Phone:960-590-0155
Practice Address - Fax:760-326-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP20421635OtherCORPORATION REGISTRATION NUMBER
AZ205332Medicaid