Provider Demographics
NPI:1124140124
Name:BRISTOL, HEATHER ELAINE (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELAINE
Last Name:BRISTOL
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 ROCK ST APT 6
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-2501
Mailing Address - Country:US
Mailing Address - Phone:650-281-8618
Mailing Address - Fax:
Practice Address - Street 1:701 E EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2833
Practice Address - Country:US
Practice Address - Phone:650-934-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CAPA19441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer