Basic Information
Provider Information | |||||||||
NPI: | 1780718262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIDDLESWORTH | ||||||||
FirstName: | MIKALA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 365 STOUT DRIVE BOX 70403 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376141703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234394515 | ||||||||
FaxNumber: | 4234394060 | ||||||||
Practice Location | |||||||||
Address1: | 2151 CENTURY LN | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376044469 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239262500 | ||||||||
FaxNumber: | 4239265999 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 07/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1858 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 004986 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.