Provider Demographics
NPI:1841643525
Name:EVANS, BRIDGET A
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:A
Last Name:EVANS
Suffix:
Gender:F
Credentials:
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 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-691-8070
Mailing Address - Fax:270-691-8026
Practice Address - Street 1:2816 VEACH RD
Practice Address - Street 2:SUITE 403
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6295
Practice Address - Country:US
Practice Address - Phone:270-684-1145
Practice Address - Fax:270-681-1190
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY3010815363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100426150Medicaid