Provider Demographics
NPI:1821344771
Name:RYDER, STEPHEN LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:LEE
Last Name:RYDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:STE. 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:1720A MEDICAL PARK DR STE 220
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2127
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-206-1192
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0055028Medicaid