Provider Demographics
NPI:1346307253
Name:GRIDER, LARRY DUANE
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DUANE
Last Name:GRIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:LARRY
Other - Middle Name:DUANE
Other - Last Name:GRIDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:102 SENATOR WAY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5107
Mailing Address - Country:US
Mailing Address - Phone:317-846-6965
Mailing Address - Fax:317-819-5071
Practice Address - Street 1:102 SENATOR WAY
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5107
Practice Address - Country:US
Practice Address - Phone:317-846-6965
Practice Address - Fax:317-819-5071
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000137A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant