Provider Demographics
NPI:1972155935
Name:BUENO, RIDER
Entity Type:Individual
Prefix:
First Name:RIDER
Middle Name:
Last Name:BUENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RIDER
Other - Middle Name:OMAR
Other - Last Name:BUENO FONSECA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4913 FM 517 RD E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-6094
Mailing Address - Country:US
Mailing Address - Phone:832-340-7951
Mailing Address - Fax:832-340-7786
Practice Address - Street 1:4913 FM 517 RD E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-6094
Practice Address - Country:US
Practice Address - Phone:832-340-5951
Practice Address - Fax:832-340-7786
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX971397163W00000X
TX1074259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse