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General NPI Number Information
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NPI Number | 1720085996
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Entity Type | Individual
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Provider Name | JONATHAN DRU RIDDLE CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/03/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4916 OVERTON PLZ
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City | FT WORTH
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State | TX
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Zip | 76109-4415
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Country | US
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Telephone | 817-734-7980
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Fax |
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Provider Business Mailing Address
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Address Line | 4916 OVERTON PLZ
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City | FT WORTH
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State | TX
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Zip | 76109-4415
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Country | US
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Telephone | 817-734-7980
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Fax |
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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 | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | APN0000010931
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License Number State | TN
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