Provider Demographics
NPI:1457760449
Name:BRIDGES, GENESIS GAYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:GAYLE
Last Name:BRIDGES
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:1001 12TH AVE
Practice Address - Street 2:#200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-850-2000
Practice Address - Fax:817-850-2015
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01701268OtherRAILROAD
TX339472801Medicaid
TX368186YTU3Medicare PIN