Healthcare Provider Details

I. General information

NPI: 1417108481
Provider Name (Legal Business Name): CRYSTAL RYDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2269 N GREEN VALLEY PKWY
HENDERSON NV
89014-5025
US

IV. Provider business mailing address

8965 ELATI CT
LAS VEGAS NV
89148-5391
US

V. Phone/Fax

Practice location:
  • Phone: 702-855-0500
  • Fax:
Mailing address:
  • Phone: 845-807-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014236-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002162
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2006
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55433
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07239
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: