Provider Demographics
NPI:1417285115
Name:RADER, COLIN JR (PA)
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:
Last Name:RADER
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-3009
Mailing Address - Country:US
Mailing Address - Phone:318-353-3412
Mailing Address - Fax:318-353-3413
Practice Address - Street 1:160 SAN ANTONIO AVE
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3009
Practice Address - Country:US
Practice Address - Phone:318-353-3412
Practice Address - Fax:318-353-3413
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2377698Medicaid