1134424641 NPI number — NATHANAEL W RIDGE PA, PHD

Table of content: NATHANAEL W RIDGE PA, PHD (NPI 1134424641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134424641 NPI number — NATHANAEL W RIDGE PA, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDGE
Provider First Name:
NATHANAEL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134424641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5770 S 250 E
Provider Second Line Business Mailing Address:
#290
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-8100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-747-8700
Provider Business Mailing Address Fax Number:
801-747-8701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5770 S 250 E
Provider Second Line Business Practice Location Address:
#290
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-8100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-747-8700
Provider Business Practice Location Address Fax Number:
801-747-8701
Provider Enumeration Date:
01/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  68336662501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 6833666-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1780459016 . This is a "NPPES" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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