Provider Demographics
NPI:1184684425
Name:VIDAUD, RICHARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:VIDAUD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:2900 LAMB CIR
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6344
Practice Address - Country:US
Practice Address - Phone:540-731-2802
Practice Address - Fax:540-731-2230
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3119372367500000X
VA0024184195367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302071101Medicaid