MEDICARE: JONATHAN DRU RIDDLE CRNA

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	367500000X	Certified Registered Nurse Anesthetist	APN0000010931	TN

General Provider Information

NPI Number	:	1720085996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN DRU RIDDLE CRNA

Provider Business Mailing Address
First Line	:	4916 OVERTON PLZ
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76109-4415
Country	:	US
Telephone Number	:	817-734-7980
Fax Number	:

Provider Business Practice Location Address
First Line	:	4916 OVERTON PLZ
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76109-4415
Country	:	US
Telephone Number	:	817-734-7980
Fax Number	:

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

Provider Enumeration Date	:	07/03/2005
Last Update Date	:	07/08/2007

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