Healthcare Provider Details

I. General information

NPI: 1891857199
Provider Name (Legal Business Name): PAMELA RYDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 STREETER HILL RD
JEFFERSON NY
12093
US

IV. Provider business mailing address

PO BOX 460
MIDLAND PARK NJ
07432-0460
US

V. Phone/Fax

Practice location:
  • Phone: 646-498-3049
  • Fax:
Mailing address:
  • Phone: 646-498-3049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number330006
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: