Provider Demographics
NPI:1043362296
Name:BRIDWELL, LARRY JOE JR (FNP)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOE
Last Name:BRIDWELL
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5642
Mailing Address - Country:US
Mailing Address - Phone:510-752-0164
Mailing Address - Fax:510-752-7014
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:510-752-0164
Practice Address - Fax:510-752-7014
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16829OtherNP