# TRI-STATE VASCULAR GROUP, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1366993818
- **Authorized official:** WANTZY COOPER D.O. (OWNER/MEMBER MANAGER)
- **Authorized official phone:** (760) 590-0155

## Contact information

- **Practice address:** 1401 BAILEY AVE BLDG A, NEEDLES, CA 92363-3103
- **Practice address phone:** (960) 590-0155
- **Practice address fax:** (760) 326-7170
- **Mailing address:** PO BOX 9893, FORT MOHAVE, AZ 86427-9893
- **Mailing address phone:** (928) 788-4944
- **Mailing address fax:** (928) 788-4949

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | — | NULL | Yes |
| 2086S0129X | Vascular Surgery Physician | — | — | Yes |
| 208D00000X | General Practice Physician | — | NULL | — |
| 208D00000X | General Practice Physician | — | — | — |

## Other

- **Enumeration date:** 10/19/2016
- **Last updated:** 04/08/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 205332 | — | AZ |
| 01 | — | P20421635 | CORPORATION REGISTRATION NUMBER | AZ |