Healthcare Provider Details

I. General information

NPI: 1265816466
Provider Name (Legal Business Name): TRISTYN RICHENDIFER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 5TH ST
DOUGLAS WY
82633-2434
US

IV. Provider business mailing address

808 RIVERBEND DR
DOUGLAS WY
82633-2054
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-6200
  • Fax:
Mailing address:
  • Phone: 307-358-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPT639
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: