Healthcare Provider Details

I. General information

NPI: 1942293055
Provider Name (Legal Business Name): ROBBY C RIDDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5952 BLACKSTONE WAY
NINE MILE FALLS WA
99026-4900
US

IV. Provider business mailing address

3600 LIND AVE SW STE 100
RENTON WA
98057-4934
US

V. Phone/Fax

Practice location:
  • Phone: 509-464-3627
  • Fax: 509-466-9517
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00041763
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: