Provider Demographics
NPI:1851390009
Name:RIDER, MARY F (APN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:F
Last Name:RIDER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 FM 2854
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-2740
Mailing Address - Country:US
Mailing Address - Phone:936-539-4004
Mailing Address - Fax:936-539-3635
Practice Address - Street 1:704 FM 2854
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2740
Practice Address - Country:US
Practice Address - Phone:936-539-4004
Practice Address - Fax:936-539-3635
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509208363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039623603Medicaid
TX8A4528Medicare ID - Type Unspecified