Provider Demographics
NPI:1649717091
Name:RIDGWAY, BLAKE RANDALL (CRNA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:RANDALL
Last Name:RIDGWAY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 W EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4615
Mailing Address - Country:US
Mailing Address - Phone:316-644-3355
Mailing Address - Fax:
Practice Address - Street 1:1800 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3006
Practice Address - Country:US
Practice Address - Phone:281-249-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100088367500000X
TX826001367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered