Basic Information
| Provider Information | |||||||||
| NPI: | 1407814924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDWELL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | SLADE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 507 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164618288 | ||||||||
| FaxNumber: | 8164616586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727563546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796360200 | ||||||||
| FaxNumber: | 4799362912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CO1557 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.