Basic Information
| Provider Information | |||||||||
| NPI: | 1295010924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRONG | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | CHEPKOECH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIPKILEL | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | CHEPKOECH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1137 S DUPREE AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380123255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317790902 | ||||||||
| FaxNumber: | 7317790905 | ||||||||
| Practice Location | |||||||||
| Address1: | 1137 S DUPREE AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380123255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317790902 | ||||||||
| FaxNumber: | 7317790905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 04/03/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2668 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.