Provider Demographics
NPI:1801912258
Name:RIDER, KRISTIN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 NEW WAVERLY PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7406
Mailing Address - Country:US
Mailing Address - Phone:919-858-8360
Mailing Address - Fax:919-858-8408
Practice Address - Street 1:580 NEW WAVERLY PL
Practice Address - Street 2:SUITE 120
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7406
Practice Address - Country:US
Practice Address - Phone:919-858-8360
Practice Address - Fax:919-858-8408
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical