Provider Demographics
NPI:1689848624
Name:BRIDGES, KENNETH R (NP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7130 BELL ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-7003
Mailing Address - Country:US
Mailing Address - Phone:806-373-4010
Mailing Address - Fax:806-331-6373
Practice Address - Street 1:7130 BELL ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-7003
Practice Address - Country:US
Practice Address - Phone:806-373-4010
Practice Address - Fax:806-331-6373
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX629915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F7977Medicare PIN