Healthcare Provider Details

I. General information

NPI: 1821344771
Provider Name (Legal Business Name): STEPHEN LEE RYDER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720A MEDICAL PARK DR STE 220
BILOXI MS
39532-2127
US

IV. Provider business mailing address

6300 E LAKE BLVD STE. 301
VANCLEAVE MS
39565-6770
US

V. Phone/Fax

Practice location:
  • Phone: 228-230-2663
  • Fax: 228-206-1192
Mailing address:
  • Phone: 228-230-2663
  • Fax: 228-206-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00168
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: