Provider Demographics
NPI:1982696050
Name:RYDER, RENEE B (NP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:B
Last Name:RYDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 16TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4058
Mailing Address - Country:US
Mailing Address - Phone:208-467-7684
Mailing Address - Fax:208-467-7684
Practice Address - Street 1:223 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP364A363LF0000X
WI3743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAPPRMedicaid
WI20270-0711Medicare PIN