Provider Demographics
NPI:1023100831
Name:RIDDLE, CHAD (CRNA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6899
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0899
Mailing Address - Country:US
Mailing Address - Phone:502-640-8349
Mailing Address - Fax:502-749-9202
Practice Address - Street 1:4034 SAINT IVES CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3814
Practice Address - Country:US
Practice Address - Phone:502-640-8349
Practice Address - Fax:502-749-9202
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28279632A367500000X
KY1092142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered