Healthcare Provider Details

I. General information

NPI: 1720902380
Provider Name (Legal Business Name): TRISTEN JERRY LOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CITY ST
NEWDALE ID
83436-7716
US

IV. Provider business mailing address

PO BOX 93
NEWDALE ID
83436-0093
US

V. Phone/Fax

Practice location:
  • Phone: 208-360-0193
  • Fax:
Mailing address:
  • Phone: 208-360-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number230368
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: