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General NPI Number Information
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NPI Number | 1164656716
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Entity Type | Individual
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Provider Name | TRISTAN LEIGH WILD O.D.
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Gender | Female
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Dates
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Enumeration Date | 05/12/2009
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Last Update Date | 07/05/2009
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Provider Practice Location Address
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Address Line | 1700 RANCH ROAD 620 S #A
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City | LAKEWAY
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State | TX
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Zip | 78734-6245
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Country | US
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Telephone | 512-263-9970
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Fax |
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Provider Business Mailing Address
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Address Line | 7201 RANCH ROAD 2222 #2116
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City | AUSTIN
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State | TX
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Zip | 78730-3208
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Country | US
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Telephone | 901-626-4940
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 7438T
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License Number State | TX
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