Healthcare Provider Details

I. General information

NPI: 1730532508
Provider Name (Legal Business Name): TRI-STATE SPECIALISTS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PIERCE ST STE 300
SIOUX CITY IA
51104-3765
US

IV. Provider business mailing address

2730 PIERCE ST
SIOUX CITY IA
51104-3796
US

V. Phone/Fax

Practice location:
  • Phone: 712-224-8677
  • Fax: 712-277-1662
Mailing address:
  • Phone: 712-224-8677
  • Fax: 712-277-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA143916
License Number StateIA

VIII. Authorized Official

Name: MR. LEE MICHAEL HILKA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 712-226-7146