Organization
TRI-STATE VASCULAR GROUP, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WANTZY COOPER D.O. (OWNER/MEMBER MANAGER)
(760) 590-0155
Entity
Organization
Contact information
Practice address
1401 BAILEY AVE BLDG A, NEEDLES, CA 92363-3103
(960) 590-0155
(760) 326-7170
Mailing address
PO BOX 9893, FORT MOHAVE, AZ 86427-9893
(928) 788-4944
(928) 788-4949
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
—
—
208D00000X
General Practice Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
205332
—
AZ
01
—
P20421635
CORPORATION REGISTRATION NUMBER
AZ
Enumeration date
10/19/2016
Last updated
04/08/2024
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