Provider Demographics
NPI:1689620031
Name:RIDENOUR, RODNEY E (PAC)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:E
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-6038
Mailing Address - Country:US
Mailing Address - Phone:605-328-2883
Mailing Address - Fax:
Practice Address - Street 1:7220 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6038
Practice Address - Country:US
Practice Address - Phone:605-328-2883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD970021575Medicare PIN
SDS41001Medicare PIN
S85830Medicare UPIN
SD970030687Medicare PIN