Healthcare Provider Details

I. General information

NPI: 1871975839
Provider Name (Legal Business Name): TRISTA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 05/24/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 HOWARD AVE
ALTOONA PA
16601-4804
US

IV. Provider business mailing address

PO BOX 98
BEAVERDALE PA
15921-0098
US

V. Phone/Fax

Practice location:
  • Phone: 814-889-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA057662
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: