Provider Demographics
NPI:1649793241
Name:RIDENOUR, ADAM JOHN (CNP)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JOHN
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 EUCLID AVE # MSO
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4625
Mailing Address - Country:US
Mailing Address - Phone:1440-953-6082
Mailing Address - Fax:440-953-6101
Practice Address - Street 1:7956 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4806
Practice Address - Country:US
Practice Address - Phone:440-255-6040
Practice Address - Fax:440-255-3637
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021244363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner