Provider Demographics
NPI:1609003656
Name:BRIDGER, AUTUMN REJOICE (DO)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:REJOICE
Last Name:BRIDGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:REJOICE
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-2156
Mailing Address - Fax:814-373-2159
Practice Address - Street 1:505 POPLAR ST
Practice Address - Street 2:209
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3057
Practice Address - Country:US
Practice Address - Phone:814-373-2156
Practice Address - Fax:814-373-2159
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS016885208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102944294Medicaid