Basic Information
| Provider Information | |||||||||
| NPI: | 1174044259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 LEAHY ST STE 315A | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317275244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317284936 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 5101023386 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 5101025356 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.