Provider Demographics
NPI:1205428430
Name:GEORGE, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 4TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2883
Mailing Address - Country:US
Mailing Address - Phone:308-237-1102
Mailing Address - Fax:
Practice Address - Street 1:4111 4TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2883
Practice Address - Country:US
Practice Address - Phone:308-237-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist