Provider Demographics
NPI:1518337583
Name:RIDDLE, THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:RIDDLE
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 1:550 SUMMIT AVE
Mailing Address - Street 2:SUITE 2ND FLOOR
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3047
Mailing Address - Country:US
Mailing Address - Phone:937-335-0361
Mailing Address - Fax:
Practice Address - Street 1:550 SUMMIT AVE
Practice Address - Street 2:SUITE 2ND FLOOR
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3047
Practice Address - Country:US
Practice Address - Phone:937-335-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant