Provider Demographics
NPI:1245696178
Name:RISDON, CLINTON
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:RISDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1334
Mailing Address - Country:US
Mailing Address - Phone:806-796-3000
Mailing Address - Fax:
Practice Address - Street 1:3419 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1334
Practice Address - Country:US
Practice Address - Phone:806-796-3000
Practice Address - Fax:806-796-3006
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129981367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered