Provider Demographics
NPI:1790718336
Name:BRISTOW, LISA ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 FARMVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8234
Mailing Address - Country:US
Mailing Address - Phone:315-699-2716
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-299-5451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered