Basic Information
| Provider Information | |||||||||
| NPI: | 1790196616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASHINGTON | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | MONTRALE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942772 | ||||||||
| FaxNumber: | 3374942928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2626 S LOOP W STE 265 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770545636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137969955 | ||||||||
| FaxNumber: | 7137969779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-9952 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 305934 | LA | N | Allopathic & Osteopathic Physicians | Family Medicine | 2084P0800X | E-9952 | AR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207Q00000X | S8262 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | AR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.