Provider Demographics
NPI:1336524693
Name:CRIDER, IAN NATHANIEL (PT)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:NATHANIEL
Last Name:CRIDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-825-0069
Mailing Address - Fax:270-824-9777
Practice Address - Street 1:1529 HUNT CLUB BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-6066
Practice Address - Country:US
Practice Address - Phone:615-428-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100362650Medicaid
KYK188400Medicare PIN