Provider Demographics
NPI:1952992240
Name:CLEMENS, BRIDGET MACKENZIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:MACKENZIE
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:BRIDGET
Other - Middle Name:LOUISE
Other - Last Name:MACKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1433 KAYLANN DR
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9623
Mailing Address - Country:US
Mailing Address - Phone:414-510-8913
Mailing Address - Fax:
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant