Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204E00000X | Oral & Maxillofacial Surgeon | 01031765A | IN |
N | 204E00000X | Oral & Maxillofacial Surgeon | 4581 | MT |
N | 208200000X | Surgeon | 01031765A | IN |
N | 208600000X | Surgeon | 01031765A | IN |
N | 208200000X | Surgeon | 4581 | MT |
N | 208600000X | Surgeon | 4581 | MT |
N | 2082S0105X | Plastic Hand Surgeon | 01031765A | IN |
N | 2082S0105X | Plastic Hand Surgeon | 4581 | MT |
NPI | 1134213796 |
---|---|
Provider Name | Dr. Tristan Vaun Stonger |
First Address | Peru, IN 46970-2231 |
Second Address | Peru, IN 46970-2231 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 31/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B29159 | (02) | IN |