Provider Demographics
NPI:1497010250
Name:RIDDLE, TANYA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:NICOLE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:NICOLE
Other - Last Name:TRYNOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3701 S CLARKSON ST STE 400
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3960
Practice Address - Country:US
Practice Address - Phone:303-761-7797
Practice Address - Fax:303-789-2995
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0059031207N00000X
MN60608207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology