MEDICARE: MRS. DONNA BRIDGWATER LSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	SA00166	TX
2	363AS0400X	Surgical Physician Assistant	SA00166	TX

General Provider Information

NPI Number	:	1780741215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA BRIDGWATER LSA

Provider Business Mailing Address
First Line	:	7324 SOUTHWEST FWY STE 1550
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77074-2053
Country	:	US
Telephone Number	:	832-804-8716
Fax Number	:	832-804-8816

Provider Business Practice Location Address
First Line	:	7324 SOUTHWEST FWY STE 1550
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77074-2053
Country	:	US
Telephone Number	:	832-804-8716
Fax Number	:	832-804-8816

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	10/24/2018

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