Provider Demographics
NPI:1083369938
Name:RIDER, KEATON JAMES
Entity Type:Individual
Prefix:
First Name:KEATON
Middle Name:JAMES
Last Name:RIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6948 CAMPOS AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 W D.L. INGRAM AVE
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-784-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5ALJ4N051C00AB1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical TechniciansGroup - Single Specialty