Provider Demographics
NPI:1093058687
Name:RYDER, KATIE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:RYDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:GROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2985 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-523-3373
Mailing Address - Fax:
Practice Address - Street 1:2985 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7554
Practice Address - Country:US
Practice Address - Phone:208-523-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 3999390200000X
IDO-1589207RI0011X
FLOS13949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology