Provider Demographics
NPI:1184000770
Name:RIDER, PAIGE (PTA)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 WALDEN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-2842
Mailing Address - Country:US
Mailing Address - Phone:716-651-0100
Mailing Address - Fax:716-651-0151
Practice Address - Street 1:3260 WALDEN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-2842
Practice Address - Country:US
Practice Address - Phone:716-651-0100
Practice Address - Fax:716-651-0151
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY66010041225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant