Healthcare Provider Details

I. General information

NPI: 1124557913
Provider Name (Legal Business Name): CODY RIDEOUT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/21/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MAPLE ST
GILFORD NH
03249-6580
US

IV. Provider business mailing address

14 MAPLE ST
GILFORD NH
03249-6580
US

V. Phone/Fax

Practice location:
  • Phone: 603-528-9100
  • Fax: 603-524-5743
Mailing address:
  • Phone: 603-528-9100
  • Fax: 603-524-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1217
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1217
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: