MEDICARE: JUSTIN STODDARD BIDWELL PA-C

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	363A00000X	Physician Assistant	PA9102405	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	U0897Y	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437264256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN STODDARD BIDWELL PA-C

Provider Business Mailing Address
First Line	:	5880 49TH ST N
Second Line	:	SUITE N-104
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2150
Country	:	US
Telephone Number	:	727-528-6100
Fax Number	:	727-528-7895

Provider Business Practice Location Address
First Line	:	5880 49TH ST N
Second Line	:	SUITE N-104
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2150
Country	:	US
Telephone Number	:	727-528-6100
Fax Number	:	727-528-7895

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/29/2021

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Directions to “ JUSTIN STODDARD BIDWELL PA-C” Practice Location

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