Healthcare Provider Details

I. General information

NPI: 1083854848
Provider Name (Legal Business Name): LUCIANO TRISTAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NAPA VALLEJO HWY.
NAPA CA
94558-6293
US

IV. Provider business mailing address

2100 NAPA VALLEJO HWY.
NAPA CA
94558-6293
US

V. Phone/Fax

Practice location:
  • Phone: 707-253-5654
  • Fax: 707-253-5097
Mailing address:
  • Phone: 707-253-5654
  • Fax: 707-253-5097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number21723
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number21723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: