Provider Demographics
NPI:1750423554
Name:RIDEOUT, ANGELA S (ARNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:RIDEOUT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00156414363L00000X
WAAP30006959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9648007Medicaid
WA1092699Medicaid
WA1092699Medicaid
WA9648007Medicaid
WAG8859136Medicare PIN
WAG8875764Medicare PIN
WAG8871430Medicare PIN
WAG8859138Medicare PIN
WAG8859139Medicare PIN
WAG8859137Medicare PIN