Provider Demographics
NPI:1851753669
Name:BIDLAKE-PRICHARD, JOHNATHEN (AEMT)
Entity Type:Individual
Prefix:
First Name:JOHNATHEN
Middle Name:
Last Name:BIDLAKE-PRICHARD
Suffix:
Gender:M
Credentials:AEMT
Other - Prefix:
Other - First Name:JOHNATHEN
Other - Middle Name:
Other - Last Name:PRICHARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AEMT
Mailing Address - Street 1:PO BOX 2133
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NV
Mailing Address - Zip Code:89403-2133
Mailing Address - Country:US
Mailing Address - Phone:775-291-4204
Mailing Address - Fax:
Practice Address - Street 1:104 STATE ROUTE 447
Practice Address - Street 2:
Practice Address - City:NIXON
Practice Address - State:NV
Practice Address - Zip Code:89424
Practice Address - Country:US
Practice Address - Phone:775-291-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV70515146M00000X
NVA2011866146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate