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NPI Code Detail

MEDICARE: MISS LATISHA OLIVIA BRISTOL PA

MEDICARE: MISS LATISHA OLIVIA BRISTOL PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0110004651VA
2363A00000XPhysician AssistantPA030279DC

General Provider Information

NPI Number : 1265597538
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS LATISHA OLIVIA BRISTOL PA
Provider Business Mailing Address
First Line : 5000 COX RD
Second Line :
City : GLEN ALLEN
State : VA
Zip : 23060-9263
Country : US
Telephone Number : 804-968-5700
Fax Number :
Provider Business Practice Location Address
First Line : 60 PROSPERITY LN
Second Line :
City : STAFFORD
State : VA
Zip : 22556-4605
Country : US
Telephone Number : 540-658-2811
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/26/2006
Last Update Date : 02/15/2021

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Directions to “ MISS LATISHA OLIVIA BRISTOL PA” Practice Location

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