Provider Demographics
NPI:1316912843
Name:BRISTER, TRENT SMITH (PA-C)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:SMITH
Last Name:BRISTER
Suffix:
Gender:M
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 1:3353 63RD SQ
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-6553
Mailing Address - Country:US
Mailing Address - Phone:772-778-6711
Mailing Address - Fax:
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-778-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3641363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLX1616OtherBLUE CROSS
FL291010100Medicaid
FLP00253779OtherRAILROAD
FLP00253779OtherRAILROAD