Provider Demographics
NPI:1710556352
Name:RIDDLE, MARY VICTORIA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:VICTORIA
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SHOAL CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7274
Mailing Address - Country:US
Mailing Address - Phone:803-760-8984
Mailing Address - Fax:
Practice Address - Street 1:200 SHOAL CREEK CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7274
Practice Address - Country:US
Practice Address - Phone:803-760-8984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant