Provider Demographics
NPI:1720085996
Name:RIDDLE, JONATHAN DRU (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DRU
Last Name:RIDDLE
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 1:4916 OVERTON PLZ
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4415
Mailing Address - Country:US
Mailing Address - Phone:817-734-7980
Mailing Address - Fax:
Practice Address - Street 1:4916 OVERTON PLZ
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4415
Practice Address - Country:US
Practice Address - Phone:817-734-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010931367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered