Provider Demographics
NPI:1720714850
Name:REDICAN, IDA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MARIE
Last Name:REDICAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 COURT SIDE CIR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-7362
Mailing Address - Country:US
Mailing Address - Phone:775-671-0669
Mailing Address - Fax:
Practice Address - Street 1:897 IRONWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-5198
Practice Address - Country:US
Practice Address - Phone:775-782-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV848652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner