MEDICARE: JASON RYAN RIDENOUR FNP

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	363LF0000X	Family Nurse Practitioner	71017046A	IN

General Provider Information

NPI Number	:	1740160167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON RYAN RIDENOUR FNP

Provider Business Mailing Address
First Line	:	675 S 100 W
Second Line	:
City	:	FRANKLIN
State	:	IN
Zip	:	46131-8432
Country	:	US
Telephone Number	:	317-919-7650
Fax Number	:

Provider Business Practice Location Address
First Line	:	5160 E SOUTHPORT RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-9601
Country	:	US
Telephone Number	:	317-672-2773
Fax Number	:

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

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	09/05/2025

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