Provider Demographics
NPI:1215378377
Name:BRIDGEWATER, TYLER ASHTON (FNP-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ASHTON
Last Name:BRIDGEWATER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 FOXBORO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-6002
Mailing Address - Country:US
Mailing Address - Phone:801-244-8968
Mailing Address - Fax:
Practice Address - Street 1:401 S 400 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4933
Practice Address - Country:US
Practice Address - Phone:801-295-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7078841-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily