NPIMap

Individual provider Active NPI

Desyrae Eliza Ridenour

  • Physician Assistant
  • Springfield, MO
National Provider Identifier
1891557575
Registry record updated Apr 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
2024003095 Issued in MO
Practice address
960 E Walnut Lawn St Ste 201
Springfield, MO 65807-7865
Phone
(417) 269-4450
Fax
(417) 269-4470
NPI assigned
Jan 29, 2024
Sex
Female
Sole proprietor
No

Organizations & group practices 19

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Lester E Cox Medical Centers 240 clinicians

Practice addresses (Care Compare)

3801 S National Ave 9TH FL
Glycemic MGMT Services
Springfield, MO 65807-5210
Phone (417) 269-5158

960 E Walnut Lawn
201 Adult Medicine and Endocrinology Speciali
Springfield, MO 65807-7865
Phone (417) 269-4450

Hospital & facility affiliations

  • Cox Medical Centers Hospital, Springfield, MO, CCN 260040
  • Cox Monett Hospital Hospital, Monett, MO, CCN 261329

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
I20240229001504 MO Practitioner - Physician Assistant 7911342993 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
2024003095MOMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Lester E Cox Medical Centers CurrentSince Apr 22, 2024 Accepting new patients
Lester E Cox Medical Centers CurrentSince Apr 22, 2024 Accepting new patients
Lester E. Cox Medical Centers Past Accepting new patients
Ozarks Medical Center Past Accepting new patients

Locations

3801 S National Ave
Ste 1122
Springfield, MO 65807

960 E Walnut Lawn St
Ste 201
Springfield, MO 65807
Phone (417) 269-4450

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 2024003095 MO Primary

Addresses

NPPES NPI Registry

Primary practice location

960 E Walnut Lawn St Ste 201
Springfield, MO 65807-7865

Mailing address

PO Box 505673
Saint Louis, MO 63150-5673
Phone (417) 730-6430

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Apr 30, 2024.

{
    "created_epoch": "1706486400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714435200000",
    "number": "1891557575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 505673",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631505673",
            "telephone_number": "417-730-6430",
            "fax_number": "417-269-7567"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "960 E WALNUT LAWN ST STE 201",
            "city": "SPRINGFIELD",
            "state": "MO",
            "postal_code": "658077865",
            "telephone_number": "417-269-4450",
            "fax_number": "417-269-4470"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RIDENOUR",
        "first_name": "DESYRAE",
        "middle_name": "ELIZA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-01-29",
        "last_updated": "2024-04-30",
        "certification_date": "2024-04-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": "2024003095",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Springfield, MO

Sources for this page

Verify at the official NPI Registry.