Healthcare Provider Details

I. General information

NPI: 1548099377
Provider Name (Legal Business Name): TRISTAN BRASS LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 05/05/2025
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 WEST 12TH STREET
LITTLE ROCK AR
72204-1513
US

IV. Provider business mailing address

P.O. BOX 251970
LITTLE ROCK AR
72225-1970
US

V. Phone/Fax

Practice location:
  • Phone: 501-666-8686
  • Fax: 501-660-6829
Mailing address:
  • Phone: 501-666-8686
  • Fax: 501-660-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA2407025
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: