Provider Demographics
NPI:1114966819
Name:BIDWELL, THERESA JAINN (FNP/PA-C)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:JAINN
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:FNP/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:PO BOX 943
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97525-0943
Mailing Address - Country:US
Mailing Address - Phone:541-821-1919
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:118-GV
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00451363AM0700X
CA392031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORVAD-000Medicare UPIN