Provider Demographics
NPI:1912684671
Name:RIDDELL, MADISON JOB (PA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:JOB
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5305
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-627-6576
Practice Address - Street 1:1802 YAKIMA AVE STE 302
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5305
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-627-6576
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61485120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant