Provider Demographics
NPI:1891752937
Name:HALLER, TRISTA (DO)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:HALLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 AUTUMN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-1301
Mailing Address - Country:US
Mailing Address - Phone:724-375-3199
Mailing Address - Fax:724-375-5858
Practice Address - Street 1:99 AUTUMN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1301
Practice Address - Country:US
Practice Address - Phone:724-375-3199
Practice Address - Fax:724-375-5858
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012473280001Medicaid
PA410807OtherUPMC
PA1756822OtherBLUE SHIELD
OH2595366Medicaid
PA089724H51Medicare PIN
PA410807OtherUPMC
PA1012473280001Medicaid