Organization
TRI-STATE MEDICAL SPECIALISTS LLC
Active
Other names
TriState Pain Institute
Organization subpart
No
Provider details
NPI number
Authorized official
KNAYA TABORA (OWNER/MEMBER MANAGER)
(928) 788-3333
Entity
Organization
Contact information
Practice address
1510 E WAGON WHEEL LN STE 110, FORT MOHAVE, AZ 86426-6698
(928) 788-3333
(928) 788-3555
Mailing address
1510 E WAGON WHEEL LN STE 110, FORT MOHAVE, AZ 86426-6698
(928) 788-3333
(928) 788-3555
Taxonomy
Speciality
Code
Description
License number
State
207LP2900X
Pain Medicine (Anesthesiology) Physician
—
—
207T00000X
Neurological Surgery Physician
20605
AZ
207T00000X
Neurological Surgery Physician
5573
NY
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
—
—
208VP0000X
Pain Medicine Physician
20605
AZ
208VP0000X
Pain Medicine Physician
5573
NV
208VP0000X
Pain Medicine Physician
Primary
—
—
208VP0014X
Interventional Pain Medicine Physician
—
—
363L00000X
Nurse Practitioner
AP3760
AZ
363L00000X
Nurse Practitioner
AP8599
AZ
363LF0000X
Family Nurse Practitioner
AP8599
AZ
363LP2300X
Primary Care Nurse Practitioner
AP8599
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
527366
—
AZ
01
—
DQ4807
MEDICARE RAILROAD GROUP PIN
AZ
Enumeration date
05/04/2010
Last updated
10/12/2023
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