Healthcare Provider Details

I. General information

NPI: 1699360065
Provider Name (Legal Business Name): TRISTAN ROMAN LUBINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 UNIVERSITY VLG
SALT LAKE CITY UT
84108-3522
US

IV. Provider business mailing address

650 ROUND VALLEY DR
PARK CITY UT
84060-7571
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number10670291-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12345127-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: