MEDICARE: TRISTAN EVERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1275112104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISTAN EVERSON

Provider Business Mailing Address
First Line	:	PO BOX 342
Second Line	:
City	:	ROWLESBURG
State	:	WV
Zip	:	26425-0342
Country	:	US
Telephone Number	:	304-594-8393
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 LANTZ RIDGE RD
Second Line	:
City	:	ROWLESBURG
State	:	WV
Zip	:	26425-9230
Country	:	US
Telephone Number	:	304-594-8393
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2021
Last Update Date	:	04/07/2021

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Directions to “ TRISTAN EVERSON ” Practice Location

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