Provider Demographics
NPI:1114912508
Name:GRYDER, SUSAN LEE (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:GRYDER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 TECH BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7871
Mailing Address - Country:US
Mailing Address - Phone:813-620-0026
Mailing Address - Fax:813-623-3322
Practice Address - Street 1:1202 TECH BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7871
Practice Address - Country:US
Practice Address - Phone:813-620-0026
Practice Address - Fax:813-623-3322
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3010512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP82713Medicare UPIN
FLY020LYMedicare ID - Type Unspecified