Provider Demographics
NPI:1316213903
Name:RIDDICK-BURDEN, GAYE SUZETTE (NP)
Entity Type:Individual
Prefix:
First Name:GAYE
Middle Name:SUZETTE
Last Name:RIDDICK-BURDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST. SUITE 701
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3308
Mailing Address - Country:US
Mailing Address - Phone:215-955-0207
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-8153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006928C363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103161142Medicaid
PA103161142Medicaid