Provider Demographics
NPI:1497021059
Name:PRIDDY, RALPH DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:DAVID
Last Name:PRIDDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 CITARA CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-4779
Mailing Address - Country:US
Mailing Address - Phone:904-814-6703
Mailing Address - Fax:
Practice Address - Street 1:2305 STATE ROAD 207
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-9329
Practice Address - Country:US
Practice Address - Phone:904-827-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant