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General NPI Number Information
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NPI Number | 1326062977
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Entity Type | Individual
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Provider Name | BRIAN D RIDGELY PA
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Gender | Male
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 06/15/2010
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Provider Practice Location Address
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Address Line | 1651 SE TIFFANY AVE
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-7564
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Country | US
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Telephone | 772-398-1800
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Fax | 772-398-1815
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Provider Business Mailing Address
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Address Line | PO BOX 417
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City | STUART
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State | FL
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Zip | 34995-0417
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Country | US
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Telephone | 772-223-5665
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Fax | 772-223-5646
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA3524
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License Number State | FL
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