Provider Demographics
NPI:1073988291
Name:RIDER, REBECCA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:RIDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:SHUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:
Practice Address - Street 1:325 N ENOLA RD
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-2123
Practice Address - Country:US
Practice Address - Phone:717-732-4911
Practice Address - Fax:717-409-8948
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1577363A00000X
PAMA061858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant