Provider Demographics
NPI:1033724331
Name:RIDGWAY, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RIDGWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 RIVANNA RUN
Mailing Address - Street 2:
Mailing Address - City:FALLING WATERS
Mailing Address - State:WV
Mailing Address - Zip Code:25419-4329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 RIVANNA RUN
Practice Address - Street 2:
Practice Address - City:FALLING WATERS
Practice Address - State:WV
Practice Address - Zip Code:25419-4329
Practice Address - Country:US
Practice Address - Phone:814-494-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
MDA5083225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant