Provider Demographics
NPI:1518973270
Name:BRISTOW, CONNIE S (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:S
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3133
Mailing Address - Country:US
Mailing Address - Phone:407-207-5000
Mailing Address - Fax:
Practice Address - Street 1:3151 N ALAFAYA TRL
Practice Address - Street 2:101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-2945
Practice Address - Country:US
Practice Address - Phone:407-207-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290289300Medicaid
FLY02YJOtherBCBS
FL290289300Medicaid