Provider Demographics
NPI:1578504866
Name:RIDER, RONALD KIP (PA-C)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:KIP
Last Name:RIDER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 WASHINGTON ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8282
Mailing Address - Country:US
Mailing Address - Phone:954-967-6550
Mailing Address - Fax:954-967-6553
Practice Address - Street 1:3702 WASHINGTON ST
Practice Address - Street 2:SUITE 305
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8282
Practice Address - Country:US
Practice Address - Phone:954-967-6550
Practice Address - Fax:954-967-6553
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9100646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290649000Medicaid
FL290649000Medicaid