Healthcare Provider Details

I. General information

NPI: 1821364407
Provider Name (Legal Business Name): MICHAEL WAYNE BRIDGETT CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SOLOMONS ISLAND RD N
PRINCE FREDERICK MD
20678-3917
US

IV. Provider business mailing address

975 SOLOMONS ISLAND RD N PO BOX 980
PRINCE FREDERICK MD
20678-3917
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5400
  • Fax: 410-535-5285
Mailing address:
  • Phone: 410-535-5400
  • Fax: 410-535-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR096847
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: