Provider Demographics
NPI:1326062977
Name:RIDGELY, BRIAN D (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:RIDGELY
Suffix:
Gender:M
Credentials:PA
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 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:1651 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7564
Practice Address - Country:US
Practice Address - Phone:772-398-1800
Practice Address - Fax:772-398-1815
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290394600Medicaid
FLE0675Medicare UPIN
FL290394600Medicaid