Provider Demographics
NPI:1053845776
Name:RIDENOUR, JONATHAN R (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:8400 COUNTRY CLUB WAY
Mailing Address - Street 2:APT. L29
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-1844
Mailing Address - Country:US
Mailing Address - Phone:865-567-2465
Mailing Address - Fax:
Practice Address - Street 1:2105 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2409
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ALPA.1244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant