Provider Demographics
NPI:1043364441
Name:HAUG, TRISTEN HEITZ (PA)
Entity type:Individual
Prefix:
First Name:TRISTEN
Middle Name:HEITZ
Last Name:HAUG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRISTEN
Other - Middle Name:
Other - Last Name:HEITZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:3803 SOUTH BASCOM AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4235
Mailing Address - Country:US
Mailing Address - Phone:408-559-0988
Mailing Address - Fax:408-369-4263
Practice Address - Street 1:3803 S BASCOM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7317
Practice Address - Country:US
Practice Address - Phone:408-559-0988
Practice Address - Fax:408-369-4263
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant