Provider Demographics
NPI:1023008265
Name:SPROTT, VIDA RISTON (APRN, CNM, FNP)
Entity Type:Individual
Prefix:
First Name:VIDA
Middle Name:RISTON
Last Name:SPROTT
Suffix:
Gender:F
Credentials:APRN, CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 CALDER ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1916
Mailing Address - Country:US
Mailing Address - Phone:409-838-4472
Mailing Address - Fax:409-838-0496
Practice Address - Street 1:2965 HARRISON ST STE 313
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1113
Practice Address - Country:US
Practice Address - Phone:409-838-4472
Practice Address - Fax:877-769-2234
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX540793363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135029004Medicaid
TX135029004Medicaid
TX80255MMedicare PIN