Healthcare Provider Details

I. General information

NPI: 1306332853
Provider Name (Legal Business Name): JONATHAN MICHAEL RIDDELL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W 1ST ST
SAINT FRANCIS KS
67756-3540
US

IV. Provider business mailing address

210 W 1ST ST
SAINT FRANCIS KS
67756-3540
US

V. Phone/Fax

Practice location:
  • Phone: 785-332-2104
  • Fax:
Mailing address:
  • Phone: 785-332-2104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4317
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: