Provider Demographics
NPI:1134424641
Name:RIDGE, NATHANAEL W (PA, PHD)
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:W
Last Name:RIDGE
Suffix:
Gender:M
Credentials:PA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5770 S 250 E
Mailing Address - Street 2:#290
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8100
Mailing Address - Country:US
Mailing Address - Phone:801-747-8700
Mailing Address - Fax:801-747-8701
Practice Address - Street 1:5770 S 250 E
Practice Address - Street 2:#290
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8100
Practice Address - Country:US
Practice Address - Phone:801-747-8700
Practice Address - Fax:801-747-8701
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT68336662501103T00000X
UT6833666-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1780459016OtherNPPES