Provider Demographics
NPI:1720482912
Name:RISTVEDT, PHILIP JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JORDAN
Last Name:RISTVEDT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10503 W THUNDERBIRD BLVD
Mailing Address - Street 2:STE 262
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3048
Mailing Address - Country:US
Mailing Address - Phone:623-933-8289
Mailing Address - Fax:623-933-2596
Practice Address - Street 1:10503 W THUNDERBIRD BLVD
Practice Address - Street 2:STE 262
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3048
Practice Address - Country:US
Practice Address - Phone:623-933-8289
Practice Address - Fax:623-933-2596
Is Sole Proprietor?:No
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5878363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical