Provider Demographics
NPI:1164384038
Name:CHAMBERS, TRISTAN LEROY
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:LEROY
Last Name:CHAMBERS
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 1:916 E BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-3908
Mailing Address - Country:US
Mailing Address - Phone:260-440-9206
Mailing Address - Fax:
Practice Address - Street 1:916 E BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-3908
Practice Address - Country:US
Practice Address - Phone:260-440-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer