Healthcare Provider Details

I. General information

NPI: 1396375531
Provider Name (Legal Business Name): DILLON JAY REIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N RENAISSANCE BLVD NE STE C
ALBUQUERQUE NM
87107-7002
US

IV. Provider business mailing address

1500 N RENAISSANCE BLVD NE STE C
ALBUQUERQUE NM
87107-7002
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-5565
  • Fax:
Mailing address:
  • Phone: 505-266-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0071
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0007286
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: