Provider Demographics
NPI:1023552015
Name:BRISTOW, NICOLAS TODD (RN)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:TODD
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 54TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-9007
Mailing Address - Country:US
Mailing Address - Phone:360-628-2968
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:ATTN: MCHJ-CLQ-C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:360-628-2968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60653580163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse