Provider Demographics
NPI:1447762380
Name:BRIDGMAN, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BRIDGMAN
Suffix:
Gender:M
Credentials:
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 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:880 SW 145TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6171
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1112411363L00000X
OH0033013363L00000X
AZ291383363L00000X
FLAPRN9325995363L00000X
IL209028336363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner