Basic Information
| Provider Information | |||||||||
| NPI: | 1568494433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIST | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 13813 METRO PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339124343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399361343 | ||||||||
| FaxNumber: | 2399368507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9103450 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 010148300 | 05 | FL | MEDICAID |