Provider Demographics
NPI:1588793483
Name:RIEDEMAN, NANETTE L (PA)
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:L
Last Name:RIEDEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NANETTE
Other - Middle Name:L
Other - Last Name:DEMASI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12020
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2020
Mailing Address - Country:US
Mailing Address - Phone:888-556-5621
Mailing Address - Fax:
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-526-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15611Medicaid
CAPA15611Medicaid
CACI990ZMedicare PIN
0PA156110Medicare ID - Type Unspecified