Provider Demographics
NPI:1366749988
Name:RIEDEL, JOHN JOSEPH JR (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:RIEDEL
Suffix:JR
Gender:M
Credentials:CRNA
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 171
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-0171
Mailing Address - Country:US
Mailing Address - Phone:336-416-5935
Mailing Address - Fax:
Practice Address - Street 1:1370 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3506
Practice Address - Country:US
Practice Address - Phone:336-651-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC085705367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered