Provider Demographics
NPI:1578514725
Name:WIECZOREK, BRIDGET M (CNM)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:M
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N 162ND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2539
Mailing Address - Country:US
Mailing Address - Phone:402-397-6600
Mailing Address - Fax:
Practice Address - Street 1:515 N 162ND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2539
Practice Address - Country:US
Practice Address - Phone:402-397-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE120018367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1578514725Medicaid
NE099099194Medicare PIN
NE10026301600Medicaid
NE10026480100Medicaid
NE47068731799Medicaid