Provider Demographics
NPI:1295009926
Name:BRISTOL, ROSE SUZETTE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:SUZETTE
Last Name:BRISTOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 HICKS ST
Mailing Address - Street 2:3RD FLOOR FULLER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5509
Mailing Address - Country:US
Mailing Address - Phone:718-780-1000
Mailing Address - Fax:718-780-4911
Practice Address - Street 1:339 HICKS ST
Practice Address - Street 2:3RD FLOOR FULLER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5509
Practice Address - Country:US
Practice Address - Phone:718-780-1000
Practice Address - Fax:718-780-4911
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003327-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical