Healthcare Provider Details

I. General information

NPI: 1265287536
Provider Name (Legal Business Name): MADISON JUSTINE BRIDGEWATER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

8323 OUTPOST CIR
CHESTERFIELD VA
23832-7736
US

V. Phone/Fax

Practice location:
  • Phone: 804-483-0000
  • Fax:
Mailing address:
  • Phone: 949-446-5327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: