MEDICARE: JENTRY DANIELLE RIDDLE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MP00154600	NJ
2	363A00000X	Physician Assistant	PA05748	TX
3	363AM0700X	Medical Physician Assistant	PA05748	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003849837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENTRY DANIELLE RIDDLE PA

Provider Business Mailing Address
First Line	:	1201 SAM BASS ROAD
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-4137
Country	:	US
Telephone Number	:	512-388-1861
Fax Number	:	512-388-0373

Provider Business Practice Location Address
First Line	:	4204 EAST STAN SCHLEUTER LOOP
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-8352
Country	:	US
Telephone Number	:	254-690-2800
Fax Number	:	254-690-5401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	06/15/2009

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Directions to “ JENTRY DANIELLE RIDDLE PA” Practice Location

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