Basic Information
| Provider Information | |||||||||
| NPI: | 1649279266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDREW | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | CORNELL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA,MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | LA FAMILIA MEDICAL CENTER | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059826280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | LA FAMILIA MEDICAL CENTER | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059826280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2009-043 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 2822 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 566 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 005692-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | Z4167 | 05 | NM | MEDICAID |