Provider Demographics
NPI:1942616750
Name:RIDGEWAY, ROBERT LEE IV (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:RIDGEWAY
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:2022 CARDINAL CIR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1504
Mailing Address - Country:US
Mailing Address - Phone:864-224-7577
Mailing Address - Fax:864-225-5165
Practice Address - Street 1:2022 CARDINAL CIR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1504
Practice Address - Country:US
Practice Address - Phone:864-224-7577
Practice Address - Fax:864-225-5165
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC2119363A00000X, 363AS0400X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical