Provider Demographics
NPI:1235296492
Name:BLEDSOE, TODD B (PA)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:B
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SE BISHOP BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5537
Mailing Address - Country:US
Mailing Address - Phone:509-332-2517
Mailing Address - Fax:509-334-9247
Practice Address - Street 1:825 SE BISHOP BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5537
Practice Address - Country:US
Practice Address - Phone:509-332-2517
Practice Address - Fax:509-334-9247
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003602100Medicaid
ID003602100Medicaid