Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 6081 | MN |
NPI | 1063687721 |
---|---|
Provider Name | Kevin Riddle |
First Address | Saint Paul, MN 55102-2346 |
Second Address | Saint Paul, MN 55102-2346 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2008 |
Last Update Date | 24/04/2008 |