Provider Demographics
NPI:1932187382
Name:BRIDWELL, SHAWN (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BRIDWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 HARDCASTLE BLVD
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-8233
Mailing Address - Country:US
Mailing Address - Phone:405-527-4700
Mailing Address - Fax:405-527-4903
Practice Address - Street 1:1438 HARDCASTLE BLVD
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-8233
Practice Address - Country:US
Practice Address - Phone:405-527-4700
Practice Address - Fax:405-527-4903
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ04887Medicare UPIN