Provider Demographics
NPI:1437264256
Name:BIDWELL, JUSTIN STODDARD (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:STODDARD
Last Name:BIDWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 49TH ST N
Mailing Address - Street 2:SUITE N-104
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2150
Mailing Address - Country:US
Mailing Address - Phone:727-528-6100
Mailing Address - Fax:727-528-7895
Practice Address - Street 1:5880 49TH ST N
Practice Address - Street 2:SUITE N-104
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2150
Practice Address - Country:US
Practice Address - Phone:727-528-6100
Practice Address - Fax:727-528-7895
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291591000Medicaid
FLU0897YOtherMEDICARE PTAN
FLP00123768OtherRR MEDICARE
FL291591000Medicaid
FLU0897ZMedicare ID - Type UnspecifiedMEDICARE# FOR TAMPA