Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 2018029283 | MO |
Y | 213ES0000X | Sports Medicine | 2018029283 | MO |
NPI | 1255913059 |
---|---|
Provider Name | Matthew Ridgway |
First Address | Columbia, MO 65211-0001 |
Second Address | Columbia, MO 65211-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2021 |
Last Update Date | 22/04/2021 |