Healthcare Provider Details

I. General information

NPI: 1013832872
Provider Name (Legal Business Name): TRISTEN MICHAEL NICCUM EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2694
  • Fax: 844-231-8913
Mailing address:
  • Phone: 314-454-2694
  • Fax: 844-231-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberB-73659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: