Provider Demographics
NPI:1649779471
Name:BRIDGEMAN, KRISTOPHER (PA)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:BRIDGEMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8439
Mailing Address - Country:US
Mailing Address - Phone:815-744-4551
Mailing Address - Fax:815-744-4756
Practice Address - Street 1:951 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8439
Practice Address - Country:US
Practice Address - Phone:815-744-4551
Practice Address - Fax:815-744-4756
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085006497OtherIL PA LICENSE