Provider Demographics
NPI:1962839506
Name:RIDDER, KATELIN J (PA)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:J
Last Name:RIDDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 FARNAM DR STE 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3426
Mailing Address - Country:US
Mailing Address - Phone:402-390-4111
Mailing Address - Fax:402-390-4115
Practice Address - Street 1:222 N 192ND ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-5363
Practice Address - Country:US
Practice Address - Phone:402-390-4111
Practice Address - Fax:402-390-4115
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962839056Medicaid
NE47068731751Medicaid
NE47068731742Medicaid
NE47068731751Medicaid