Provider Demographics
NPI:1003849837
Name:RIDDLE, JENTRY DANIELLE (PA)
Entity Type:Individual
Prefix:
First Name:JENTRY
Middle Name:DANIELLE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENTRY
Other - Middle Name:DANIELLE
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 SAM BASS ROAD
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4137
Mailing Address - Country:US
Mailing Address - Phone:512-388-1861
Mailing Address - Fax:512-388-0373
Practice Address - Street 1:4204 EAST STAN SCHLEUTER LOOP
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-8352
Practice Address - Country:US
Practice Address - Phone:254-690-2800
Practice Address - Fax:254-690-5401
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP00154600363A00000X
TXPA05748363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1991747-01Medicaid
TX1991747-02Medicaid
TX8K9597Medicare PIN
TX1991747-02Medicaid
TX1991747-01Medicaid