Healthcare Provider Details

I. General information

NPI: 1437742129
Provider Name (Legal Business Name): BRIDGET BRUST PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 WEST AVE
PLAIN CITY OH
43064-1177
US

IV. Provider business mailing address

382 WEST AVE
PLAIN CITY OH
43064-1177
US

V. Phone/Fax

Practice location:
  • Phone: 614-493-7609
  • Fax:
Mailing address:
  • Phone: 614-493-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006904RX
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: