Provider Demographics
NPI:1083750590
Name:RIDNER, STANLEY LEE III
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:LEE
Last Name:RIDNER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-5134
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:365 STOUT DRIVE
Practice Address - Street 2:SUITE 160
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614
Practice Address - Country:US
Practice Address - Phone:423-439-4225
Practice Address - Fax:423-439-4560
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23528363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN23528OtherLICENSE
KY0601243Medicare PIN
KY78001872Medicaid