1174045884 NPI number — MS. TRISTA LEE RAYMOND PT, DPT

Table of content: MS. TRISTA LEE RAYMOND PT, DPT (NPI 1174045884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174045884 NPI number — MS. TRISTA LEE RAYMOND PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAYMOND
Provider First Name:
TRISTA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NORRIS
Provider Other First Name:
TRISTA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174045884
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2551 38TH AVE NE UNIT 322
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55421-5013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-894-8944
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3580 ARCADE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VADNAIS HEIGHTS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55127-7135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-968-5201
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  10462 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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