Healthcare Provider Details

I. General information

NPI: 1881044006
Provider Name (Legal Business Name): TRISTAN ROSS PEREGRINO FOWLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2016
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N MAIN ST
SIKESTON MO
63801-5043
US

IV. Provider business mailing address

1013 N MAIN ST
SIKESTON MO
63801-5043
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-7535
  • Fax: 573-472-7787
Mailing address:
  • Phone: 573-472-7535
  • Fax: 573-472-7787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number05-43441
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101022338
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: