Provider Demographics
NPI:1619082716
Name:RIDDER, MICHELE A (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:RIDDER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 STATE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-1126
Mailing Address - Country:US
Mailing Address - Phone:316-775-9191
Mailing Address - Fax:316-775-0348
Practice Address - Street 1:1306 STATE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1126
Practice Address - Country:US
Practice Address - Phone:316-775-9191
Practice Address - Fax:316-775-0348
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100422080CMedicaid
KS110509Medicare ID - Type UnspecifiedMEDICARE GROUP ID
KSP60224Medicare UPIN
KS178951Medicare ID - Type UnspecifiedRURAL HEALTH MEDICARE
KS100422080CMedicaid