Provider Demographics
NPI:1982833745
Name:BRIDGE, TISHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:L
Last Name:BRIDGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VIRGINIA AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5882
Mailing Address - Country:US
Mailing Address - Phone:772-464-6551
Mailing Address - Fax:
Practice Address - Street 1:900 VIRGINIA AVE STE 10
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5882
Practice Address - Country:US
Practice Address - Phone:772-464-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9110899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical