Basic Information
| Provider Information | |||||||||
| NPI: | 1538299888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDLEY | ||||||||
| FirstName: | ALES | ||||||||
| MiddleName: | CALEB | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293865222 | ||||||||
| FaxNumber: | 2293826191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 JOHN ORR DR | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293865222 | ||||||||
| FaxNumber: | 2293826191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.