Provider Demographics
NPI:1669188967
Name:RUNYON, TRISTAN GEORGE
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:GEORGE
Last Name:RUNYON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 140TH ST NW
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-6795
Mailing Address - Country:US
Mailing Address - Phone:630-999-5466
Mailing Address - Fax:
Practice Address - Street 1:9514 4TH ST NE UNIT 101
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-1937
Practice Address - Country:US
Practice Address - Phone:425-397-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP161362588225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant