Healthcare Provider Details

I. General information

NPI: 1114219466
Provider Name (Legal Business Name): TRISTAN NADIENE FUJITA ATC-R, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 130
GRESHAM OR
97030-3722
US

IV. Provider business mailing address

16790 SE DAVIDOFF WAY
DAMASCUS OR
97089-5807
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-1122
  • Fax:
Mailing address:
  • Phone: 360-204-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-10139459
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: