Provider Demographics
NPI:1952349862
Name:KENNY, BRIDGET SAGE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:SAGE
Last Name:KENNY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:ROSE
Other - Last Name:SAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7775 ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7427
Mailing Address - Country:US
Mailing Address - Phone:269-321-7546
Mailing Address - Fax:269-321-1705
Practice Address - Street 1:7775 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7427
Practice Address - Country:US
Practice Address - Phone:269-321-7546
Practice Address - Fax:269-321-1705
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK0853653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N59670Medicare ID - Type Unspecified