Provider Demographics
NPI:1063715563
Name:TANO, TRISTAN T (DPT)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:T
Last Name:TANO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N MESA ST STE C7
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1535
Mailing Address - Country:US
Mailing Address - Phone:915-533-7787
Mailing Address - Fax:915-533-7788
Practice Address - Street 1:3800 N MESA ST STE C7
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1535
Practice Address - Country:US
Practice Address - Phone:915-533-7787
Practice Address - Fax:915-533-7788
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1201897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid