Healthcare Provider Details

I. General information

NPI: 1497552301
Provider Name (Legal Business Name): TRISTEN GILES PETERSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 06/29/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22746 RANDO CT
BOX ELDER SD
57719-9317
US

IV. Provider business mailing address

22746 RANDO CT
BOX ELDER SD
57719-9317
US

V. Phone/Fax

Practice location:
  • Phone: 701-449-9028
  • Fax:
Mailing address:
  • Phone: 701-449-9028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: