MEDICARE: TRI-STATE SPECIALISTS, LLP

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	363LF0000X	Family Nurse Practitioner	A143916	IA

General Provider Information

NPI Number	:	1730532508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE SPECIALISTS, LLP

Provider Business Mailing Address
First Line	:	2730 PIERCE ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-3796
Country	:	US
Telephone Number	:	712-224-8677
Fax Number	:	712-277-1662

Provider Business Practice Location Address
First Line	:	2730 PIERCE ST STE 300
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-3765
Country	:	US
Telephone Number	:	712-224-8677
Fax Number	:	712-277-1662

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. LEE MICHAEL HILKA
Credential	:
Telephone Number	:	712-226-7146

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	10/12/2018

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