Provider Demographics
NPI:1912618869
Name:BRIDEWELL, ALLYSON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:
Last Name:BRIDEWELL
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 1:6400 PASEO DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1718
Mailing Address - Country:US
Mailing Address - Phone:505-596-2100
Mailing Address - Fax:
Practice Address - Street 1:222 VAIL CT
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-2854
Practice Address - Country:US
Practice Address - Phone:505-923-5362
Practice Address - Fax:505-620-5354
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant