Provider Demographics
NPI:1669425385
Name:BIDWELL, ROGER J (ARNP)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:J
Last Name:BIDWELL
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:MR
Other - First Name:ROGER
Other - Middle Name:J
Other - Last Name:BIDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:21107 DONAHOO RD
Mailing Address - Street 2:PO BOX 996
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-4153
Mailing Address - Country:US
Mailing Address - Phone:913-742-4084
Mailing Address - Fax:913-742-4086
Practice Address - Street 1:21107 DONAHOO RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-4153
Practice Address - Country:US
Practice Address - Phone:913-742-4084
Practice Address - Fax:913-742-4086
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44815363L00000X
MO128639363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
26279011OtherBC/BS
KS100347550AMedicaid
500008410OtherRAILROAD MEDICARE
KS160288Medicare ID - Type Unspecified