Provider Demographics
NPI:1104821008
Name:RIDGE, LAURA B (RPA-C)
Entity type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:B
Last Name:RIDGE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 SOUTHWESTERN BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1239
Mailing Address - Country:US
Mailing Address - Phone:716-677-3065
Mailing Address - Fax:716-712-0497
Practice Address - Street 1:3065 SOUTHWESTERN BLVD
Practice Address - Street 2:STE 104
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1239
Practice Address - Country:US
Practice Address - Phone:716-677-3065
Practice Address - Fax:716-712-0497
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008329363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP52696Medicare UPIN
NYPA0578Medicare ID - Type Unspecified