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General NPI Number Information
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NPI Number | 1548917172
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Entity Type | Organization
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Legal Business Name | TRISTAN L WILD OD PLLC
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Dates
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Enumeration Date | 03/03/2022
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Last Update Date | 03/03/2022
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Provider Practice Location Address
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Address Line | 1700 RANCH ROAD 620 S STE A
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City | LAKEWAY
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State | TX
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Zip | 78734-6246
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Country | US
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Telephone | 512-263-9970
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Fax | 512-895-9903
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Provider Business Mailing Address
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Address Line | 1700 RANCH ROAD 620 S STE A
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City | LAKEWAY
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State | TX
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Zip | 78734-6246
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Country | US
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Telephone | 512-263-9970
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Fax | 512-895-9903
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Authorized Official
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Title or Position | OWNER
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Name | DR. TRISTAN WILD
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Credential | OD
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Telephone | 512-263-9970
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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 |
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License Number State |
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