Provider Demographics
NPI:1407814924
Name:BRIDWELL, JUSTIN SLADE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:SLADE
Last Name:BRIDWELL
Suffix:
Gender:M
Credentials:CRNA
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 507
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0507
Mailing Address - Country:US
Mailing Address - Phone:816-461-8288
Mailing Address - Fax:816-461-6586
Practice Address - Street 1:1200 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3546
Practice Address - Country:US
Practice Address - Phone:479-636-0200
Practice Address - Fax:479-936-2912
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCO1557367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00397004Medicare PIN
AR5Y606C741Medicare PIN