Provider Demographics
NPI:1376568360
Name:BRISTOW, DAVID WALTER (FNP PAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WALTER
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:FNP PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 RALEY BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-8351
Mailing Address - Country:US
Mailing Address - Phone:530-345-9455
Mailing Address - Fax:
Practice Address - Street 1:111 RALEY BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-8351
Practice Address - Country:US
Practice Address - Phone:530-345-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13525363A00000X
CA487125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily