Provider Demographics
NPI:1396745683
Name:RIDDLEBERGER, KEVIN W (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:RIDDLEBERGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PROFESSIONAL LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6972
Mailing Address - Country:US
Mailing Address - Phone:303-772-1600
Mailing Address - Fax:303-772-9317
Practice Address - Street 1:1551 PROFESSIONAL LN
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:303-772-1600
Practice Address - Fax:303-772-9317
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1801363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54570867Medicaid
CO54570867Medicaid
CO809242Medicare PIN