Provider Demographics
NPI:1003312539
Name:BRISTOW, MICHAEL ERIC (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 BELFORT RD
Mailing Address - Street 2:BLDG 400
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6026
Mailing Address - Country:US
Mailing Address - Phone:904-580-4730
Mailing Address - Fax:
Practice Address - Street 1:11481 OLD SAINT AUGUSTINE RD STE 303
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1476
Practice Address - Country:US
Practice Address - Phone:904-580-4730
Practice Address - Fax:904-580-4740
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3200922363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology