Provider Demographics
NPI:1164528329
Name:RIDGWAY, ELIZABETH WILSON (MD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:WILSON
Last Name:RIDGWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:557 E. BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1029
Mailing Address - Country:US
Mailing Address - Phone:307-733-4627
Mailing Address - Fax:307-733-5184
Practice Address - Street 1:557 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-4627
Practice Address - Fax:307-733-5184
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2241-A208000000X
IDM-8159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY10452700Medicaid
WY10452700Medicaid