Provider Demographics
NPI:1376859454
Name:RIDER, MICHAEL JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:RIDER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 JOHN F KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-3865
Mailing Address - Country:US
Mailing Address - Phone:563-556-8332
Mailing Address - Fax:563-556-8334
Practice Address - Street 1:1900 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-3865
Practice Address - Country:US
Practice Address - Phone:563-556-8332
Practice Address - Fax:563-556-8334
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-126465367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered