Provider Demographics
NPI:1164435418
Name:GLADER, DEMETRIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:L
Last Name:GLADER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEMETRIA
Other - Middle Name:LYNN
Other - Last Name:RAAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:605-341-7062
Practice Address - Street 1:7220 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8754
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:605-341-7062
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDQ30332Medicare UPIN
P00356256OtherMEDICARE RAILROAD PTAN
SD6828990Medicaid
SD1254560001OtherCIGNA MEDICARE
SD101319Medicare ID - Type Unspecified
SDS101319Medicare PIN