Provider Demographics
NPI:1104864628
Name:BLEDSOE, DONALD W (ANP-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:W
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST STE 802
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2726
Mailing Address - Country:US
Mailing Address - Phone:713-441-3780
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE # 802
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618904363LA2200X
TXAP114175363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180798402Medicaid